Commentary

Clinical guidelines have been defined as systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances2 in order to condense a large body of medical knowledge into a convenient, readily usable format.3 In clinical practice, they are particularly relevant for two main reasons: first, the clinical guideline can review all the available evidence and synthesise it, whereas a systematic review would focus on high-quality evidence often only from RCT; and second, the clinical guideline differs from decision analyses in that it relies more on qualitative reasoning and in emphasising a particular clinical context.4

As the guideline authors here have noted, this “is not intended to be construed or to serve as a standard of care”, but is clear that the ultimate intention was to influence what clinicians do.

The condition targeted here is dental caries in preschool children. This clinical guideline was formulated by a large and multidisciplinary team including clinicians, public health specialists and consumers' groups and organisations. It was developed for use by clinicians in Scotland, a country with one of the highest dental caries rates in Europe (mean DMFT, 2.7). Thus, the implicit goal of this guideline is to reduce the DMFT index in Scottish preschool children, at least, at the d3 level (frank decay). Although the primary target users would be dental teams working community dental clinics, ideally it would also reach parents, carers and crèche staff.

The guideline cover areas including dental caries diagnosis; caries risk assessment; dental caries prevention; and dental caries management in preschool children. It also has a chapter with recommendations for the implementation and posterior auditing of the guideline. The last chapter contains useful information for parents, which can be converted into a leaflet, and a one-page summary of all recommendations appropriate for a clinical setting.

The main body of the guideline contains statements on the evidence level that support them and the recommendation grade. It is very easy to read because it written as short paragraphs in which the evidence is explained and graded, from 1++ (evidence from high-quality systematic reviews or RCT) to 4 (expert opinion). These paragraphs are followed by a short and clear statement with the corresponding grade of recommendation, from A to D, according to the evidence level. It also has “good practice points”, which are statements that represent best practice, based on the clinical experience of the guideline development group.

The critical appraisal of a clinical guideline involves three key questions:4

  1. 1)

    Are the results of this guideline valid? (ie, was an explicit and sensible process used to identify, select and combine evidence?)

  2. 2)

    What are the results? (ie, are practical, clinically important recommendations made?)

  3. 3)

    Will the results help me care for my patients? (ie, are the recommendations applicable to my patients?)

As alluded above, a clinical guideline is constructed using all the available evidence, not just high-quality data such as that from RCT. The large number of references (181) indicates that the search for articles published in English was exhaustive. This guideline cited 23 systematic reviews or meta-analyses.

One slightly curious aspect is that the definition of caries is taken from the book by Kidd5 although, later, the guideline's authors note that dental caries can be prevented, something explicitly denied in Kidd's book and in two others references cited by the authors.6, 7 These references highlight that strictly speaking the caries process cannot be prevented, only controlled to the extent that a visible carious lesion does not develop.

What is clear is that the status of the primary dentition can predict caries in permanent teeth8, 9, 10 and therefore most of the recommendations are either: to intervene early or prevent carious lesions; carry out caries risk assessments; or specific dietary recommendations. For example, recommendations include toothbrushing with fluoride toothpaste (even for children under 2 years old, with a smear size amount of fluoride) and oral health promotion programmes for parents and continued postnatal care — a recommendation based on evidence from nonanalytical studies (case reports or case series) that in fact represents evidence from clinical trials.11

Of the 33 recommendations in the guideline, six are supported by high-quality evidence, 14 by a grade-B levels of evidence, nine with grade C, and four with grade D. The latter represents evidence from nonanalytical studies, expert opinion or that extrapolated from other studies. Even with the extensive panel of experts who developed this guideline, expert opinion was rarely used to fill the gaps found in literature.

The principal aim of evidence-based healthcare is to develop methods that can assist practitioners to provide the most appropriate, compassionate and ethical care to the public.12 The large body of evidence distilled in this guideline indicates that preventive and management measures should begin as early as possible, indeed before birth. In addition, oral health promotion programmes should include not only parents but also teachers and community workers to be effective. The instructions and recommendations given are not sufficient if carried out in the clinical setting alone: the dentist will have to play an important role as a community educator. One specific intervention, the use of fluoride at home, should be universal, regardless of a child's risk of caries. Meanwhile, as regards use in the clinic, the dental professional should choose the form of topical fluoride according to specific risk.

For healthy teeth or suspicious surfaces, sealants can be satisfactorily applied to primary molars. The management of frank or active carious lesions should be focused on the removal of infected dentine and the effective sealing of the cavity. For the treatment of extensive tooth decay, the guideline mentions that formocresol therapy should be replaced, but it does not give any alternative. This recommendation could have been strengthened if an alternative intervention had been suggested.

This guideline does not include a clinical algorithm, but its last page serves as a summary of recommendations. This is important because continued reinforcement of the recommendations should increase the impact of the guideline.13

Practitioners wish to use resources efficiently. This desire is met by the guideline because the majority of the recommended interventions are easy to implement in public dental settings. It is worth mentioning, however, that there is no recommendation about when to refer to a paediatric dentist.

Although this guideline was developed for use in Scotland, its recommendations can be implemented in any country that wishes to reduce the cost and pain associated with management of dental decay in preschool children. It is a call not to delay the prevention and treatment of dental caries to permanent teeth only. Fortunately, the times when primary teeth were seen as “replaceable” are over.