1.1 Background: the need for a guideline

Oral and dental health have improved tremendously over the last century but the prevalence of dental caries in children remains a significant clinical problem which is a priority for the NHS in Scotland.

In addition, dental and oral health have not improved uniformly across the Scottish population. The prevalence of caries is now markedly skewed, with 9% of 5 year olds and 6% of 14 year olds experiencing 50% of the untreated decayed surfaces.^{2, 3}
(A review of the epidemiology of dental caries, including a report on needs assessment, is available from the Scottish Needs Assessment Programme.^{4, 5})

There also appears to be considerable clinical variation in the type of care currently being provided. This may reflect a degree of uncertainty as to which treatments are most useful, who would benefit from treatment and which treatments will achieve cost effective health gain. There are, however, proven professionally and self-applied preventive techniques which can address these problems and which can be targeted to help those with the greatest need.

All health professionals recognise the difficulties in identifying the most appropriate care for their patients. This is as true for dentistry as any other field. There is often a gap between the research identifying an effective clinical practice and its widespread adoption. As the volume of new knowledge and publications increase year on year, this gap becomes wider. Clinical practice guidelines are one available tool to help the practitioner keep up to date and identify best practice.

1.2 The Scottish Intercollegiate Guidelines Network

The Scottish Intercollegiate Guidelines Network (SIGN) was established in 1993 by the medical Royal Colleges and their Faculties in Scotland to support the development of evidence-based national guidelines for the NHS in Scotland. The membership of SIGN includes all the medical specialties, nursing, pharmacy, dentistry, professions allied to medicine, and patient representatives.

Clinical practice guidelines have been defined as 'systematically developed statements which assist in decision making about appropriate health care for specific clinical conditions'.⁶ It is important to emphasise that guidelines do not aim to restrict clinical freedom but to help the clinician identify the optimal management for an individual patient, while recognising that every patient is unique.

SIGN guidelines are developed by multidisciplinary development groups and are based on a systematic review of the evidence of best practice (see Annex 1), following a standard methodology designed to balance scientific rigour with an open and consultative approach. ⁷ The guideline recommendations are graded according to the strength of the supporting evidence, enabling areas of relative certainty and uncertainty to be clearly identified by the clinician. (See inside front cover for definitions of the levels of evidence and grades of recommendations used in the guideline.)

1.3 Remit of the guideline

This guideline makes recommendations for the targeted prevention of dental caries in the permanent teeth of 6-16 year olds presenting for dental care.

The focus on this specific group followed widespread concern about the scale of the caries problem in Scottish teenagers, the uneven distribution of the disease in adolescents, and variations in clinical caries management. Effective targeted prevention of caries in the permanent dentition has great potential to achieve significant health gain, given that once an initial filling is placed a repetitive, costly, lifelong cycle of re-restoration occurs for many individuals. Prevention from age six is important if the first permanent molars are to be adequately protected and should build on preventive programmes for 0-5 year olds. Caries prevention in pre-school children is important but is outwith the remit of this guideline.

It was felt that the literature review and guideline should be restricted to those individuals who present for dental care in order to narrow the subject area to a manageable size. General Medical Practitioners have an important role in communicating positive oral health messages to individuals who present for medical care but who do not seek regular dental care; and in encouraging those at high risk of caries to present for dental care.

1.4 Structure of the guideline

The structure of the guideline has been designed to reflect the philosophy of modern caries management which has emerged from caries research over the last 15 years. Section 2 summarises contemporary terminology and provides definitions. Section 3 deals with primary prevention in terms of caries risk factors, identifying those at high caries risk and consideration of the interventions which have been shown to be effective. Section 4 links both secondary and tertiary prevention as these are often intertwined in clinical practice. Subsequent sections provide relevant information for non-dental health professionals, considerations about implementing the guideline and recommendations for audit and research.

The guideline does not represent a comprehensive account of all possible preventive measures for dental caries. In some cases this is because there is insufficient, high quality research evidence available (to date, randomised controlled trials are infrequently carried out in dentistry). Within this document, gaps in the evidence have been highlighted for future research. In some instances where insufficient evidence has been found, statements are offered representing the consensus view of the multidisciplinary guideline development group as to recommended good clinical practice.

1.5 Who is the guideline for?

This guideline is intended for dentists working in primary dental care (general dental service, community dental service), dental schools and hospitals. However, the guideline has been developed to be of interest to other health care workers including general medical practitioners, health visitors and pharmacists and also to patients. Non-dental health professionals as well as dental professionals have an important part to play in the prevention of dental caries. Section 5 contains more information for non-dental professionals.