Skip to main content
Download PDF

Clinical practice guideline adaptation for risk-based caries management in 18–55 year-old Iranian adults

BMC Oral Health volume 23, Article number: 7 (2023) Cite this article

Abstract

Purpose

To adapt an evidence-based clinical practice guideline (CPG) for risk-based management of caries in 18–55 year-old Iranian adults.

Methods

A multidisciplinary adaptation team reviewed evidence-based guidelines such as the NICE, SIGN, and ADA according to the defined clinical questions. In addition, databases such as the PubMed and Google Scholar were searched and CPGs were screened and appraised using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) tool. Clinical scenarios were developed and their level of evidence, clinical advantage and adaptability were assessed. Following a two-round ranking by experts, the final recommendations were selected using the RAND-UCLA appropriateness method.

Results

Of 17 CPGs, 5 were selected as the source guidelines for adaptation. To assess the risk of caries in the adult population, reduced Cariogram (without saliva tests) and CAMBRA were suggested as diagnostic tools. In addition, 53 risk-based recommendations on the preventive care (including the use of fluoride toothpaste, fluoride, and chlorhexidine mouthwash, at home and in-office fluoride gel, fluoride varnish, mouth buffering, and sealant), operative intervention threshold, and follow-up interval were adapted for Iranian adults.

Conclusions

A guideline was adapted for risk-based management of dental caries in Iranian adults. This helps local dentists in decision making and promoting oral health of adults. Further research is needed to assess the external validity and feasibility of the adapted guideline in the Iranian population.

Peer Review reports

Introduction

Clinical practice guidelines (CPGs) represent a series of recommendations based on the best available evidence, mainly systematic reviews, to guide healthcare providers in clinical decision-making and to reduce practice diversities. CPGs can also reduce health inequalities and health expenses [1]. Despite these advantages, available CPGs may not be widely used in developing countries due to resource limitations, health system differences, and varied prevalence and incidence rates of the target disease [2]. Considering time, financial and human resources required for developing a new local CPG, adaptation of available CPGs is considered an option [3].

Caries risk assessment (CRA) is defined as determining the probability of developing new carious lesions or progression of existing carious lesions during a certain period [4, 5]. According to the literature, certain risk factors and risk indicators influence the occurrence or progression of dental caries, such as past caries experience, enamel defects, dental biofilm, oral hygiene, diet, and socioeconomic status of the individuals [6]. Many CRA tools are now available in the form of checklists such as the CAMBRA [7] and ADA [8] or as software programs such as the Cariogram [9] and Previser [10].

The predictive validity of these tools is still under investigation, especially in different settings [11,12,13]. Caries risk assessment is considered essential for delivering a suitable preventive regimen and to manage a non-cavitated carious lesion properly [14, 15]. Risk-based management of carious lesions includes a combination of patient’s caries risk assessment and delivering preventive care. This approach includes oral hygiene instructions, diet counseling, dry mouth management [16], pit and fissure sealants [17], at-home use of fluoride products such as toothpaste and mouth rinses with different fluoride concentrations [18], in-office topical fluoride therapy such as application of gels or varnishes [19], use of antimicrobial agents such as chlorhexidine mouthrinse or gel [20], and use of xylitol chewing gum or lozenges [21].

The patient’s risk status, costs, culture, and availability of resources in the region must be considered in formulating a treatment plan. Therefore, the adapted CPGs are considered as one of the main sources of evidence-based clinical decision-making [3]. The prevalence of dental caries is high in Iranian adults. The mean DMFT ranges from 4.3 in 18-year-olds [22] to 13.2 in the age group of 35–44 years [23]. Besides, Iranian dentists tend to over-treat low-risk patients [24] and have insufficient knowledge and practice regarding caries risk assessment and risk management [25]. Considering the inconsistencies regarding risk-based management of caries among available guidelines, and since no CPGs are available on caries management in adults in Iran, the aim of the present study was to adapt an evidence-based CPG for risk-based caries management in 18–55 year-old Iranian adults.

Materials and methods

Guideline adaptation steps were followed according to the Iranian Ministry of Health and Medical Education’s national model for CPG adaptation [3]. This model was proposed based on reviewing valid CPG adaptation models such as ADAPTE [26]. The study started after obtaining clearance from the National Committee of Ethics in Biomedical Research (IR.TUMS.DENTISTRY.REC.1400.092).

Steering committee and expert panel

A multidisciplinary team of 10 experts was assembled, including three dental public health specialists, two restorative dentistry specialists, two oral disease specialists, one general dentist, two epidemiologists with previous experience of guideline adaptation (one of them was a general dentist), and an expert searcher. The panel members were selected by convenience sampling from faculty members of Tehran University of Medical Sciences. Most of them had at least five years of experience in dental practice in public and private settings and two of them were former members of the Strategy Planning Committee of the Oral Health Office of the Ministry of Health.

The steps were clearly explained to all members and they were asked to verbally declare any conflict of interest (COI) based on items mentioned in ADAPTE toolkit ver.2.0 COI disclosure sample [26]. The panel members were contacted via email and WhatsApp for individual scorings and in person for further discussion.

Defining clinical questions

In order to prioritize the CPG scopes and clinical questions, a list of potential measures was extracted from (1) primary screening of existing guidelines on this topic and their recommendations, (2) informal interviews with general dentists and specialists, and (3) a literature review regarding Iranian dentists’ knowledge, attitude and practice. These measures were further prioritized based on importance, cost-effectiveness, availability, and being similar or controversial among different guidelines, different practitioners, and different risk groups.

Fifty-four clear and specific clinical questions were defined according to the PIPOH framework [27]. In the present study, the PIPOH framework included (P) Patient population: 18–55 year-old Iranian adults at risk of caries including low-risk, medium-risk, high-risk, and extreme-risk, (I) Intervention: preventive and non-invasive measures, (P) Professionals: general dentists, (O) Outcome: decreased caries incidence or progression rate, (H) Healthcare setting: primary and secondary dental care providers.

To assign adults in the above caries risk groups, the reduced Cariogram software (without saliva tests) or the CAMBRA form (in the absence of the reduced Cariogram software) was suggested based on a previous study [28]. The output of the Cariogram is Actual chance to avoid new cavities in percentage categorized as low risk (76–100%), medium-risk (51–75%), high-risk (26–50%) and extreme-risk (0–25%) [9]. The latest version of the CAMBRA risk assessment tool directly assigns the patients to the four caries risk groups from low to extreme based on its scorings [7].

Searching for CPGs

A search was conducted in national and international websites publishing CPGs such as the NICE [29] and SIGN [30] as well as specialized dentistry websites such as the ADA [31] and CDA [32] using the following key words: dental caries, caries risk assessment, caries management, caries prevention, dental care, guideline, practical guideline, clinical practice guideline, protocol, government publication. The major search engines such as the PubMed and Google Scholar were also searched using specific search strategies (Additional file 1). The search was limited to clinical practice guidelines addressing caries management considering the caries risk published between 2000 and 2022 in English. The guidelines specific to children and adolescents were excluded. The included websites and search engines are listed in Table 1.

Table 1 List of websites included in searching for CPGs
Full size table

A complementary search was also conducted to identify the related evidence such as recent systematic reviews, cost-effectiveness studies and local data to assist in updating and adapting the recommendations of retrieved guidelines (Additional file 1). In addition, the ADA guidelines on non-restorative treatment of caries [33], pit and fissure sealants [34], topical fluoride [35], and non-fluoride preventive agents [21] were also considered as adjunct guidelines in the adaptation process.

Screening and appraisal of CPGs

Relevant guidelines were first screened for (1) appropriate organization, (2) currency (publication year and latest updates), and (3) availability of the full guideline including references. In the appraisal phase, quality assessment was done using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) tool, which uses 23 items to assess the quality of a CPG in 6 domains including (1) scope and purpose, (2) stakeholders’ involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence [36]. Three members of the adaptation team independently scored each item from 1 (strongly disagree) to 7 (strongly agree). The final score was calculated using the following formula (range: 0–100 for each domain):

$$\frac{sum\;of\;the\;given\;scores\;in\;each\;domain - minimum\;possible\;score\;in\;each\;domain}{{maximum\;possible\;score\;in\;each\;domain - minimum\;possible\;score\;in\;each\;domain}}*100$$

Clinical scenarios

As described by Fitch et al. [37], clinical scenarios are defined as potential recommendations that answer clinical questions; these scenarios are accepted or rejected as final recommendations according to the expert panel scoring. Sixty-four clinical scenarios were developed by extracting PIPOH items from the existing recommendations or, if needed, from their background data and rewriting them in a desired recommendation template based on the caries risk. The clinical scenarios were assessed by the expert panel according to the national model for CPG adaptation [3] including (1) background evidence, (2) clinical advantages, and (3) adaptability. The clinical advantage of each scenario was rated considering costs, side benefits, and side effects, and their adaptability was rated based on usability, generalizability of effectiveness and acceptability from 1 (low) to 3 (high). Based on this assessment, each scenario was finally scored from 1 (completely disagree) to 9 (completely agree).

Decision-making

To achieve a consensus, Gestalt decision-making based on the RAM model (RAND-UCLA appropriateness method) was utilized [37]. In the first round of scoring, each expert ranked scenarios individually, which was further discussed and rescored for the second round in a panel meeting. The median score was calculated for each scenario, and its appropriateness was determined as inappropriate (1–3), uncertain (4–6), or appropriate (7–9). In addition, agreement was assessed according to the RAM model based on the panel size (Additional file 2) [37].

In the first round, appropriate scenarios with total agreement were accepted. Scenarios with uncertainty or disagreement were assessed individually and proposed for further discussion in the second round of the expert panel. If there was total agreement on the inappropriateness of a scenario, it was recommended to exclude it in the first round without further discussion [37]. After redetermining appropriateness and agreement in the second round, the scenarios were prioritized. The scenarios with disagreement and those considered inappropriate were excluded. The scenarios with total and partial agreement as “appropriate” were considered as the first and second priority, respectively. Those with total and partial agreement as “uncertain” were considered as the third and fourth priority, respectively. In case of having more than one scenario for a clinical question, the scenario with the highest priority was selected as the final recommendation.

Results

Seventeen relevant CPGs were retrieved of which eleven were excluded due to not providing specific risk-based recommendations for caries management and one due to unavailability of the full guide following preliminary screening (Additional file 3). Five were selected as source guidelines for adaptation and were further assessed by the AGREE II as shown in Table 2. CAMBRA [7], CariesCare [38], ICCMS [14] and Malaysian guideline [39] scored 60 or more in terms of development rigor and CMS [15] scored 59.7. All five CPGs scored 70 or more in other domains.

Table 2 Source guidelines for adaptation and their appraisal with AGREE II
Full size table

The list of 54 final adapted recommendations with their priority, source CPG(s), and background evidence is presented in Table 3 and summarized in Table 4.

Table 3 Final recommendations and their priority after two rounds of scoring based on RAND-UCLA appropriateness method
Full size table
Table 4 Summary of the final clinical recommendations by experts in adapted guideline
Full size table

The main preventive and non-preventive measures recommended by expert panels were as follows:

Fluoride toothpaste and mouthrinse

As for the fluoride concentration in the toothpaste, source guidelines recommended the use of 5000 ppm F toothpaste in high-risk and extreme-risk groups, as it is effective without the need for additional fluoride mouthrinse and hence improves the patient’s compliance [7, 14, 15, 38]. Due to unavailability of 5000 ppm F toothpaste in Iran, the expert panel recommended the use of 1000–1450 ppm F toothpaste in combination with fluoride mouthrinse in medium, high and extreme-risk groups [40, 41]. For high and extreme-risk groups, the 1450 ppm fluoride toothpaste was recommended, which seems reasonable due to its higher effectiveness compared to the 1000–1250 ppm F toothpaste [42]. As a substitute, brushing with F toothpaste more than twice a day was not recommended due to insufficient evidence [43]. Despite the need for standardization and labelling of the local fluoride products, most fluoride toothpastes contain an optimum level of fluoride (1000 ppm) [44, 45].

Chlorhexidine mouthrinse

The literature is controversial regarding the use of chlorhexidine (CHX) mouthwash for caries prevention. According to a guideline by Anuwar et al. [39] adapted from a Scottish guideline [46], chlorhexidine mouthrinse administration is not recommended due to insufficiency of evidence. This statement is based on a study by Twetman [47] in 2004 that reviewed 22 controlled clinical trial studies on chlorhexidine gel or mouthrinse, and found that only one study compared the effectiveness of CHX mouthrinse with educational program. On the contrary, the CAMBRA guideline [7] recommends the use of chlorhexidine mouthrinse in addition to fluoride mouthrinse based on two randomized clinical trials in 2012 and 2018. In these studies, the use of chlorhexidine mouthrinse for one week every month and fluoride mouthrinse in other weeks, was effective in reducing the load of Streptococcus mutans and caries increment [20, 48]. Similarly, the ICCMS guideline states that “chlorhexidine may be considered as a preventive measure in some countries” [14]. In our guideline, the panel members adopted a similar regimen for high and extreme-risk patients although it might not be accepted by all patients due to its difficulty.

Fluoride gel/varnish

The expert panel suggested no professionally-applied fluoride for low-risk patients. For other risk groups, fluoride therapy at 3- to 6-month intervals was recommended in line with the latest national guideline on fluoride therapy [49]. The expert panel members preferred fluoride varnish over gel as it is more convenient and less time consuming although its stickiness may be unpleasant for adult patients. In the ADA [35] and ICCMS [14] guidelines, gel or varnish administration is recommended and neither is preferred to the other. However, evidence on fluoride varnish is more conclusive as suggested by a more recent meta-analysis [50]. The main factors to be considered are the high fluoride concentration, i.e., 22,600 ppm in varnish and 12,300 ppm in gel and the regular application [35]. At-home fluoride gel application was recommended for extreme risk groups, in case of caries progression despite using other measures [7].

Pit and fissure sealants

The ICCMS guideline recommends sealing all at-risk surfaces in medium-risk, high-risk, and extreme-risk patients [14]. However, in the present study, the expert panel members considered this recommendation as uncertain and had incomplete agreement over it in medium-risk patients since it may not be cost-effective to use this method for medium-risk adults in our setting [51]. In addition, the quality of sealant application by some dentists may not be ideal [52].

Restorative treatment threshold

Regarding the restorative treatment threshold, although there is evidence on the probability of the cessation of proximal caries limited to the enamel, dentinoenamel junction (DEJ), or outer third of dentine [53,54,55], there were different recommendations on non-restorative treatment of these lesions in guidelines. In this guide, the expert panel members accepted recommendations on non-restorative treatment of proximal caries limited to DEJ in low-risk and medium- risk patients and proximal caries limited to outer third of dentine in low-risk patients with uncertainty and incomplete agreement. Non-restorative treatment of lesions limited to outer third of dentine is recommended in ADA, CMS, ICCMS, and CariesCare guidelines [14, 15, 33, 38]. The expert panel members rejected recommendations on non-restorative treatment of proximal caries limited to outer third of dentine in medium-risk patients with complete agreement in contrast to the CMS guideline [15].

The main concerns of the expert panel regarding non-restorative treatment were non-attendance of patients for routine follow-up in Iran and a high probability of caries progression and pulpal involvement. In a study by Schwendicke et al., the international experts recommended non-restorative treatment for proximal caries limited to outer third of dentine. However, it was argued that the treatment threshold needed to be modified if the patient’s risk modification was unsuccessful or reassessment of the caries risk was not possible [56].

Follow-up interval

In the adapted guideline, 3- to 12-month risk-based follow-up intervals, consistent with in-office fluoride therapy intervals, were recommended. A recent systematic review indicated no or little difference between 6-month and 3- to 24-month risk-based follow-up intervals during which no specific preventive intervention was provided [57]. However, studies offering preventive care at certain intervals reported decreased caries increments [20, 48, 58, 59]. The panel members did not approve 24-month intervals in low-risk patients due to possible shifts in the caries risk in the long term based on the patient’s condition such as experiencing emotional difficulties, pregnancy, or diet change.

Discussion

In the present study, after reviewing the relevant CPGs and using the AGREE II tool, 54 recommendations on preventive measures including the use of fluoride toothpaste, fluoride, and chlorhexidine mouthwash, at home and in-office fluoride gel, fluoride varnish, mouth buffering, and sealant, non-preventive measures including restorative treatment threshold, and follow-up interval were adapted. The majority of these recommendations were considered “appropriate” with “total agreement” after a two-round ranking according to the RAND-UCLA appropriateness method by a multidisciplinary expert panel.

In the present study, to ensure reproducibility, appropriate manuals including the AGREE II and RAND-UCLA appropriateness method were used to select high-quality guidelines and achieve consensus. Regarding the AGREE II appraisal checklist, the cut-off points for acceptance were set based on previous similar studies [39, 60]. The RAND-UCLA appropriateness method was preferred to informal consensus or classic Delphi since it offers a more systematic and reproducible approach [61,62,63].

Our method was similar to the methods used by Lee et al. [60] as the “ADAPTE process and Delphi consensus” and by Irajpour et al. [64] as the “modified ADAPTE”. By contrast, in a study by Anuwar and Ab-Murat [39], the recommendations were finalized by receiving feedback from external reviewers and addressing them in the development committee.

Many guidelines recommended similar preventive measures. However, these measures were distributed differently among risk groups in these guidelines. This matter highlights the great influence of contextual factors, especially financial sources, and disease prevalence on formulating the recommendations [65].

In the present study, we did not include very low-risk groups in the classification, which seems reasonable due to the high prevalence of caries in Iran and the common culture of not attending regular dental check-ups [66]. However, very low-risk groups might be considered in Scandinavian countries as described by Bratthall and Hänsel [9] in the Cariogram tool guide.

To develop a practical guideline, as proposed by the New Zealand Guidelines Group [67], we embraced preventive and non-preventive measures that were considered to be very important and cost-effective according to the literature and experts’ opinions. Moreover, there were practice variations regarding their distributing among different risk groups.

We included preventive measures that are regionally available at a reasonable cost such as fluoride varnishes, which are sufficiently produced by the domestic industry. Products that are not currently available in Iran such as chlorhexidine varnishes or imported products that are available but at high price such as Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) pastes and xylitol gums were not included and may be reconsidered in future updates of the adapted guideline. Some other measures that are already well accepted and similar in all guidelines for all risk groups, like “diet counselling” were excluded only from the adaptation process and will be added to final implementation protocol as proposed by the national model for CPG adaptation.

To the best our knowledge, the present study offers the first adapted guideline on caries risk management for Iranian adults. It also distributes different available preventive and non-preventive measures based on the caries risk. We clearly defined risk groups based on validated CRA tools. A specific method or tool for CRA is not proposed in many caries management guidelines, which may act as a possible barrier for the widespread uptake of the guideline as mentioned by external reviewers of a similar study [39].

In the present study, we considered the best available evidence and the opinions of a multidisciplinary expert panel on costs, benefits, adaptability, and acceptability by dentists and patients. The patients' values and preferences were not directly considered and should be further evaluated and addressed during guideline implementation. Another limitation of the present study was that we could not take advantage of key policy-makers or administrative experts of the Ministry of Health in the adaptation process due to time limitations.

As another potential limitation, cost assessment was limited to expert panel members’ discussions on the cost of different products and services in public or private settings, indicating the need for further economic evaluation. It should be noted that this study is the initiation of the ongoing process of CPG adaptation and further stages including external review, publication, implementation, monitoring and periodic updates are still in the planning stages.

Conclusions

In the present study, an adapted clinical guideline was prepared for risk-based management of dental caries in the adult population. This adapted clinical guideline must help clinicians and healthcare providers to deliver preventive oriented services to improve the oral health and reduce health expenditures in Iran. The next stages of this project are external validation, feasibility assessment, addressing patients’ values and preferences, economic evaluations, and stakeholders’ actions. Writing a proposal for these stages and formal publication of the chairside guideline in national websites are in progress.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ADA:

American Dental Association

ADAPTE:

A Manual and Resource Toolkit for guideline adaptation

AGREE II:

Appraisal of Guidelines for Research & Evaluation II tool

CAMBRA:

Caries Management by Risk Assessment

CMS:

Caries Management System

COI:

Conflict of interest

CPP-ACP:

Casein phosphopeptide-amorphous calcium phosphate

DEJ:

Dentinoenamel junction

ICCMS:

International Caries Classification and Management System

NICE:

National Institute for Health and Care Excellence

PIPOH:

Patient population, intervention, professional, outcome, healthcare setting

RAM:

RAND/UCLA appropriateness method

SIGN:

Scottish Intercollegiate Guidelines Network

References

  1. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–30.

    Article  Google Scholar 

  2. Almazrou SH, Alfaifi SI, Alfaifi SH, Hakami LE, Al-Aqeel SA. Barriers to and facilitators of adherence to clinical practice guidelines in the middle east and north Africa region: a systematic review. Healthcare (Basel, Switzerland). 2020;8(4):564.

    Google Scholar 

  3. Yazdani SSA, Nejati M, Heydarpour P, Ahmadi A. clinical practice guideline adaptation model in I.R Iran. Iranian Ministry of Health and Medical Education; 2015.

  4. Young DA, Featherstone JD. Implementing caries risk assessment and clinical interventions. Dent Clin N Am. 2010;54(3):495–505.

    Article  Google Scholar 

  5. Twetman S, Fontana M. Patient caries risk assessment. Monogr Oral Sci. 2009;21:91–101.

    Article  Google Scholar 

  6. Fejerskov O, Nyvad B, Kidd E. Dental caries: the disease and its clinical management. 3rd ed. Oxford: Wiley Blackwell; 2015.

    Google Scholar 

  7. Featherstone JDB, Crystal YO, Alston P, Chaffee BW, Doméjean S, Rechmann P, et al. Evidence-based caries management for all ages-practical guidelines. Front Oral Health. 2021;2(14):657518.

    Article  Google Scholar 

  8. Caries Risk Assessment Form (Age >6). In: ADA Resources. American Dental Association. 2011. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/caries-risk-assessment-and-management. Accessed 5 July 2021.

  9. Bratthall D, Hänsel PG. Cariogram—a multifactorial risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol. 2005;33(4):256–64.

    Article  Google Scholar 

  10. The PreViser Oral Risk and Health Assessment Website. https://previser.co.uk/previser/. Accessed 1 June 2021.

  11. Tellez M, Gomez J, Pretty I, Ellwood R, Ismail AI. Evidence on existing caries risk assessment systems: are they predictive of future caries? Community Dent Oral Epidemiol. 2013;41(1):67–78.

    Article  Google Scholar 

  12. Su N, Lagerweij MD, van der Heijden G. Assessment of predictive performance of caries risk assessment models based on a systematic review and meta-analysis. J Dent. 2021;110:103664.

    Article  Google Scholar 

  13. Cagetti MG, Bontà G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health. 2018;18(1):123.

    Article  Google Scholar 

  14. Pitts NB, Ismail AI, Martignon S, Ekstrand K, Douglas GVA, Longbottom C. ICCMS™ Guide for Practitioners and Educators. King's College London Dental Institute; 2014.

  15. Evans RW, Pakdaman A, Dennison PJ, Howe EL. The caries management system: an evidence-based preventive strategy for dental practitioners. Application for adults. Aust Dent J. 2008;53(1):83–92.

    Article  Google Scholar 

  16. Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet. 2007;369(9555):51–9.

    Article  Google Scholar 

  17. Ahovuo-Saloranta A, Forss H, Walsh T, Hiiri A, Nordblad A, Mäkelä M, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev. 2013;3:Cd001830.

    Google Scholar 

  18. Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;2003(4):Cd002782.

    Google Scholar 

  19. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2002;3:Cd002279.

    Google Scholar 

  20. Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, et al. A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries management by risk assessment). Caries Res. 2012;46(2):118–29.

    Article  Google Scholar 

  21. Rethman MP, Beltrán-Aguilar ED, Billings RJ, Hujoel PP, Katz BP, Milgrom P, et al. Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations. J Am Dent Assoc. 2011;142(9):1065–71.

    Article  Google Scholar 

  22. Hessari H, Vehkalahti MM, Eghbal MJ, Samadzadeh H, Murtomaa HT. Oral health and treatment needs among 18-year-old Iranians. Med Princ Pract. 2008;17(4):302–7.

    Article  Google Scholar 

  23. Khoshnevisan M, Ghasemianpour M, Samadzadeh H, Baez R. Oral Health Status and Healthcare System in I.R. Iran. J Contemp Med Sci. 2018;4(3):107–17.

    Google Scholar 

  24. Ghasemi H, Murtomaa H, Torabzadeh H, Vehkalahti MM. Risk-based approach in preventive practice among Iranian dentists. Oral Health Prev Dent. 2008;6(1):53–60.

    Google Scholar 

  25. Afshar MK, Torabi M, Khalafi E, Shamsadini Z, Afshar MK, Mohammadzadeh I. Knowledge, attitude and practice regarding caries risk assessment and management in general dentists—a cross sectional survey. J Evolution Med Dent Sci. 2019;8:3499–504.

    Article  Google Scholar 

  26. Brouwers M, Browman G, Burgers J, Burnand B, Coulombe M, et al. The ADAPTE process: resource toolkit for guideline adaptation. Version 2.0. The ADAPTE Collaboration; 2009.

  27. Cook C. Is clinical gestalt good enough? J Man Manip Ther. 2009;17(1):6–7.

    Article  Google Scholar 

  28. Eshrati M. Clinical practice guideline adaptation for caries risk assessment and risk management in 18–55 years old Iranian adults (Publication No. 6716) [DDS-MDPH thesis, Tehran University of Medical Sciences]; 2022. https://lib.tums.ac.ir/site/catalogue/235354.

  29. National Institute for Health and Care Excellence Database. https://www.nice.org.uk/guidance. Accessed 5 July 2021.

  30. Scottish Intercollegiate Guidelines Network guidelines Database. https://www.sign.ac.uk/our-guidelines/. Accessed 5 July 2021.

  31. Clinical Practice Guidelines and Dental Evidence. American Dental Association Database. https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research. Accessed 10 July 2021.

  32. Agencies and Clinical Resources. California Dental Association Database. https://www.cda.org/Home/Practice/Practice-Support/Agencies-and-Clinical-Resources. Accessed 10 July 2021.

  33. Slayton RL, Urquhart O, Araujo MWB, Fontana M, Guzmán-Armstrong S, Nascimento MM, et al. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. J Am Dent Assoc. 2018;149(10):837-49.e19.

    Article  Google Scholar 

  34. Wright JT, Crall JJ, Fontana M, Gillette EJ, Nový BB, Dhar V, et al. Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: a report of the American Dental Association and the American Academy of Pediatric Dentistry. J Am Dent Assoc. 2016;147(8):672-82.e12.

    Article  Google Scholar 

  35. Weyant RJ, Tracy SL, Anselmo TT, Beltrán-Aguilar ED, Donly KJ, Frese WA, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013;144(11):1279–91.

    Article  Google Scholar 

  36. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42.

    Article  Google Scholar 

  37. Fitch K, Bernstein SJ, Aguilar MD, Burnand B. The RAND/UCLA Appropriateness Method User's Manual. RAND; 2001.

  38. Martignon S, Pitts NB, Goffin G, Mazevet M, Douglas GVA, Newton JT, et al. CariesCare practice guide: consensus on evidence into practice. Br Dent J. 2019;227(5):353–62.

    Article  Google Scholar 

  39. Anuwar AHK, Ab-Murat N. Developing clinical practice guidelines for dental caries management for the Malaysian population through the ADAPTE trans-contextual adaptation process. Oral Health Prev Dent. 2021;19(1):217–27.

    Google Scholar 

  40. Marinho VC, Higgins JP, Sheiham A, Logan S. Combinations of topical fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical fluoride for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2004;2004(1):Cd002781.

    Google Scholar 

  41. Zero DT. Dentifrices, mouthwashes, and remineralization/caries arrestment strategies. BMC Oral Health. 2006;6(Suppl 1):S9.

    Article  Google Scholar 

  42. Walsh T, Worthington HV, Glenny AM, Marinho VC, Jeroncic A. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database Syst Rev. 2019;3(3):Cd007868.

    Google Scholar 

  43. Kumar S, Tadakamadla J, Johnson NW. Effect of toothbrushing frequency on incidence and increment of dental caries: a systematic review and meta-analysis. J Dent Res. 2016;95(11):1230–6.

    Article  Google Scholar 

  44. Pakdaman A, Akbari Adegani B. Assessment of fluoride in commonly used local and imported toothpastes in the Iranian market. JDM. 2018;31(3):162–6.

    Google Scholar 

  45. Movahhed T, Bagheri H, Dehghani M, Pourtaghi M, Shirkhanikelagari Z. Evaluation of the total and soluble fluoride concentration of toothpastes available in the Iranian market. Res Dent Sci. 2019;16(2):117–26.

    Article  Google Scholar 

  46. Scottish Dental Clinical Effectiveness Programme (SDCEP). Prevention and Management of Dental Caries in Children: Dental Clinical Guidance. 2nd edn. Dundee: Scottish Dental Clinical Effectiveness Programme; 2018.

  47. Twetman S. Antimicrobials in future caries control? A review with special reference to chlorhexidine treatment. Caries Res. 2004;38(3):223–9.

    Article  Google Scholar 

  48. Rechmann P, Chaffee BW, Rechmann BMT, Featherstone JDB. Changes in caries risk in a practice-based randomized controlled trial. Adv Dent Res. 2018;29(1):15–23.

    Article  Google Scholar 

  49. Shabani M. Fluoride therapy: fluoride effects on dental caries reduction [persian national guide]. Iranian Ministry of Health and Medical Education; 2016.

  50. Lenzi TL, Montagner AF, Soares FZ, de Oliveira RR. Are topical fluorides effective for treating incipient carious lesions? A systematic review and meta-analysis. J Am Dent Assoc. 2016;147(2):84-91.e1.

    Article  Google Scholar 

  51. Akinlotan M, Chen B, Fontanilla TM, Chen A, Fan VY. Economic evaluation of dental sealants: a systematic literature review. Community Dent Oral Epidemiol. 2018;46(1):38–46.

    Article  Google Scholar 

  52. Rafatjou R, Nobahar S, Nikfar M, Salehimehr G, Khateri D. Retention and effectiveness of dental sealant after twelve months in Iranian children. Avicenna J Dent Res. 2013;5(2):56–60.

    Article  Google Scholar 

  53. Holmgren C, Gaucher C, Decerle N, Doméjean S. Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions–non-invasive approaches through remineralisation and therapeutic sealants. Br Dent J. 2014;216(5):237–43.

    Article  Google Scholar 

  54. Mount GJ, Ngo H. Minimal intervention: early lesions. Quintessence Int. 2000;31(8):535–46.

    Google Scholar 

  55. Tellez M, Gomez J, Kaur S, Pretty IA, Ellwood R, Ismail AI. Non-surgical management methods of noncavitated carious lesions. Community Dent Oral Epidemiol. 2013;41(1):79–96.

    Article  Google Scholar 

  56. Schwendicke F, Splieth C, Breschi L, Banerjee A, Fontana M, Paris S, et al. When to intervene in the caries process? An expert Delphi consensus statement. Clin Oral Investig. 2019;23(10):3691–703.

    Article  Google Scholar 

  57. Fee PA, Riley P, Worthington HV, Clarkson JE, Boyers D, Beirne PV. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev. 2020;10(10):Cd004346.

    Google Scholar 

  58. Featherstone JDB, Chaffee BW. The evidence for caries management by risk assessment (CAMBRA®). Adv Dent Res. 2018;29(1):9–14.

    Article  Google Scholar 

  59. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013;7:Cd002279.

    Google Scholar 

  60. Lee GH, McGrath C, Yiu CK. Developing clinical practice guidelines for caries prevention and management for pre-school children through the ADAPTE process and Delphi consensus. Health Res Policy Syst. 2016;14(1):44.

    Article  Google Scholar 

  61. Fainardi V, Caffarelli C, Bergamini BM, Biserna L, Bottau P, Corinaldesi E, et al. Management of children with acute asthma attack: a RAND/UCLA appropriateness approach. Int J Environ Res Public Health. 2021;18(23):12775.

    Article  Google Scholar 

  62. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics and guidelines for use. Am J Public Health. 1984;74(9):979–83.

    Article  Google Scholar 

  63. Power E, Thomas E, Worrall L, Rose M, Togher L, Nickels L, et al. Development and validation of Australian aphasia rehabilitation best practice statements using the RAND/UCLA appropriateness method. BMJ Open. 2015;5(7):e007641.

    Article  Google Scholar 

  64. Irajpour A, Hashemi M, Taleghani F. Clinical practice guideline for end-of-life care in patients with cancer: a modified ADAPTE process. Support Care Cancer. 2022;30(3):2497–505.

    Article  Google Scholar 

  65. Dizon JM, Machingaidze S, Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC Res Notes. 2016;9(1):442.

    Article  Google Scholar 

  66. Rezaei S, Woldemichael A, Zandian H, Homaie Rad E, Veisi N, Karami MB. Dental health-care service utilisation and its determinants in West Iran: a cross-sectional study. Int Dent J. 2018;68(3):176–82.

    Article  Google Scholar 

  67. New Zealand Guidelines Group. Handbook for the preparation of explicit evidence-based clinical practice guidelines. New Zealand Guidelines Group; 2001.

  68. Do L. Australian Research Centre for Population Oral Health. Guidelines for use of fluorides in Australia: update 2019. Aust Dent J. 2020;65(1):30–8.

    Article  Google Scholar 

  69. Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;2003(1):Cd002278.

    Google Scholar 

  70. Twetman S. Caries prevention with fluoride toothpaste in children: an update. Eur Arch Paediatr Dent. 2009;10(3):162–7.

    Article  Google Scholar 

  71. Wong MC, Clarkson J, Glenny AM, Lo EC, Marinho VC, Tsang BW, et al. Cochrane reviews on the benefits/risks of fluoride toothpastes. J Dent Res. 2011;90(5):573–9.

    Article  Google Scholar 

  72. Baysan A, Lynch E, Ellwood R, Davies R, Petersson L, Borsboom P. Reversal of primary root caries using dentifrices containing 5,000 and 1,100 ppm fluoride. Caries Res. 2001;35(1):41–6.

    Article  Google Scholar 

  73. Ekstrand K, Martignon S, Holm-Pedersen P. Development and evaluation of two root caries controlling programmes for home-based frail people older than 75 years. Gerodontology. 2008;25(2):67–75.

    Article  Google Scholar 

  74. Ekstrand KR, Poulsen JE, Hede B, Twetman S, Qvist V, Ellwood RP. A randomized clinical trial of the anti-caries efficacy of 5,000 compared to 1,450 ppm fluoridated toothpaste on root caries lesions in elderly disabled nursing home residents. Caries Res. 2013;47(5):391–8.

    Article  Google Scholar 

  75. Nordström A, Birkhed D. Preventive effect of high-fluoride dentifrice (5,000 ppm) in caries-active adolescents: a 2-year clinical trial. Caries Res. 2010;44(3):323–31.

    Article  Google Scholar 

  76. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;3:Cd002284.

    Google Scholar 

  77. Marinho VC, Higgins JP, Sheiham A, Logan S. One topical fluoride (toothpastes, or mouthrinses, or gels, or varnishes) versus another for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2004;2004(1):Cd002780.

    Google Scholar 

  78. Tasios T, Papageorgiou SN, Papadopoulos MA, Tsapas A, Haidich AB. Prevention of orthodontic enamel demineralization: a systematic review with meta-analyses. Orthod Craniofac Res. 2019;22(4):225–35.

    Article  Google Scholar 

  79. Hamza SA, Wahid A, Afzal N, Asif S, Imran MF, Khurshid Z, et al. Effect of sodium bicarbonate mouth wash on salivary pH and interleukin-1β levels among smokers. Eur J Dent. 2020;14(2):260–7.

    Article  Google Scholar 

  80. Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database Syst Rev. 2017;7(7):Cd001830.

    Google Scholar 

  81. Kühnisch J, Ekstrand KR, Pretty I, Twetman S, van Loveren C, Gizani S, et al. Best clinical practice guidance for management of early caries lesions in children and young adults: an EAPD policy document. Eur Arch Paediatr Dent. 2016;17(1):3–12.

    Article  Google Scholar 

  82. Urquhart O, Tampi MP, Pilcher L, Slayton RL, Araujo MWB, Fontana M, et al. Nonrestorative treatments for caries: systematic review and network meta-analysis. J Dent Res. 2019;98(1):14–26.

    Article  Google Scholar 

  83. Hayashi M, Momoi Y, Fujitani M, Fukushima M, Imazato S, Kitasako Y, et al. Evidence-based consensus for treating incipient enamel caries in adults by non-invasive methods: recommendations by GRADE guideline. Jpn Dent Sci Rev. 2020;56(1):155–63.

    Article  Google Scholar 

  84. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc. 1998;129(1):55–66.

    Article  Google Scholar 

  85. Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Syst Rev. 2013;3:Cd003808.

    Google Scholar 

  86. Riley P, Worthington HV, Clarkson JE, Beirne PV. Recall intervals for oral health in primary care patients. Cochrane Database Syst Rev. 2013;12:Cd004346.

    Google Scholar 

Download references

Acknowledgements

This paper is based on a DDS-MDPH thesis by ME supported by Deputy of Research, School of Dentistry, Tehran University of Medical Sciences (TUMS), under the supervision of AP and NGh and statistical advisory of MKh. We would like to acknowledge the great contribution of adaptation team members from school of dentistry, Tehran University of medical sciences, Iran. We would also like to express our gratitude to Dr. Ahmad Reza Shamshiri for his valuable advisory contributions.

Funding

No funding.

Author information

Authors and Affiliations

  1. Research Center for Caries Prevention, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran

    A. Pakdaman & M. Eshrati

  2. Community Oral Health Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

    A. Pakdaman

  3. Oral and Maxillofacial Medicine Department, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

    N. Gholizadeh

  4. Dental Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran

    M. J. Kharazifard

Authors
  1. A. Pakdaman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. N. Gholizadeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. J. Kharazifard
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. M. Eshrati
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Primary concept was introduced by AP. Data collection, arranging meetings and gathering expert panel scores were done by ME and supervised by AP, NGh and MJKh. Data analysis and manuscript preparation was done by ME and AP. All authors were involved in study design and proposal writing. All authors were involved in data interpretation, drafting, and editing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to M. Eshrati.

Ethics declarations

Ethics approval and consent to participate

The present study was approved by National Committee of Ethics in Biomedical Research, Iran (IR.TUMS.DENTISTRY.REC.1400.092). We confirm that all methods were performed in accordance with the relevant guidelines and regulations, including Helsinki Declaration. Informed consent was obtained from members of the expert panel. Panel members reported no conflict of interest. In case that any of the panel members was involved in development of source guidelines, was excluded from guideline appraisal and clinical scenarios scoring part.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Title of data: Search strategies used for identifying further guidelines, recent systematic reviews and local data based on PubMed advance search. Description of data: Describing search strategies that were used for identifying further guidelines, recent systematic reviews and local data based on PubMed advance search.

Additional file 2.

Title of data: Definitions of measurement of agreement for different panel sizes based on RAND/UCLA Appropriateness Method. Description of data: Describing the method used for assessing agreement between expert panel members.

Additional file 3.

Title of data: Preliminary screening of relevant CPGs on risk-based caries management. Description of data: Describing title, author, country, year, availability and type of recommendations of relevant CPGs for preliminary screening.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pakdaman, A., Gholizadeh, N., Kharazifard, M.J. et al. Clinical practice guideline adaptation for risk-based caries management in 18–55 year-old Iranian adults. BMC Oral Health 23, 7 (2023). https://doi.org/10.1186/s12903-022-02699-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12903-022-02699-w

Keywords

BMC Oral Health

ISSN: 1472-6831

Contact us