A scoping review of guidelines on caries management for children and young people to inform UK undergraduate core curriculum development

Abstract

Background

Current evidence in cariology teaching is not consistently reflected in paediatric dentistry in the United Kingdom (UK). Many dental schools are not consistently teaching biological approaches to caries management, with outdated or complex methods being taught outwith the purview of general dental practitioners. This scoping review aimed to map current guidelines on the management of caries in children and young people. This is part of a work package to inform the consensus and development of a UK-wide caries management curriculum for paediatric dentistry.

Methods

A search of electronic databases for peer reviewed literature was performed using Cochrane Library, MEDLINE via PubMed, TRIP Medical Database and Web of Science. Hand searching was undertaken for grey literature (citations of sources of evidence, websites of global organisations and Google Web Search™ (Google LLC, California, USA). Results from databases were screened independently, concurrently by two reviewers. Full texts were obtained, and reviewers met to discuss any disagreement for both database and hand searching.

Results

This review identified 16 guidelines suitable for inclusion. After quality appraisal, eight were selected for synthesis and interpretation. Key themes included the shift towards selective caries removal and avoidance of complete caries removal unless in specific circumstances in anterior teeth. For “early lesions” in primary and permanent teeth with and without cavitation, several guidelines recommend biological management including site specific prevention and fissure sealants.

Conclusions

This review mapping current cariology guidelines for children and young people found gaps in the literature including classification of early carious lesions and management of early cavitated lesions. Areas identified for further exploration include integration of biological caries management into treatment planning, selective caries removal and whether pulpotomy is specialist-level treatment, requiring referral. These results will inform consensus recommendations in the UK, using Delphi methods.

Introduction

Background

Concepts on the management of caries have shifted significantly over the past twenty years, with the evidence base demonstrating the efficacy and/or effectiveness, and benefits of minimally invasive dentistry (MID) [1]. Change in practice does not happen through production of evidence, but through its implementation and it can be difficult to change practitioners’ ways of working once these are established. One of the biggest opportunities to effect change in professional practice is through the undergraduate dental education of future clinicians [2]. However, the change in evidence towards MID was not reflected in the findings of a recent national survey, which found wide disparity in the content and methods of teaching caries management in children and young people (CYP) to undergraduate dental students in the UK [3]. There was wide variation in paediatric caries management methods taught to the next generation of dental practitioners, with outdated practice still evident in teaching. This impacts on the appropriateness of care provided for CYP’s oral and dental health and emphasises the need for recommendations to support a national curriculum for the management of caries in CYP. Within this work we defined children and young people as those under the age of 18, this is the definition used by the UK government, United Nations Convention on the Rights of the Child and civil legislation in England and Wales [4].

Rationale for the review

There are a number of guidelines, produced by various organisations internationally, on the management of dental caries [5, 6]. Within paediatric dentistry, there are several international groups producing such guidelines for professional bodies including the International-, American-, European- and British Associations for Paediatric Dentistry and others within the UK alone, such as the Scottish Dental Clinical Effectiveness Programme and the Scottish Intercollegiate Guidelines Network [5, 7,8,9,10,11,12,13,14,15,16,17,18]. However, these are of variable quality and each are designed for specific environments. High-quality guidelines that are UK-relevant should be informing education and practice within the UK and could be used for the development of recommendations for a core curriculum. To begin development of these, we aimed to map the recommendations from current guidelines through a scoping review. Scoping reviews can be defined as “a type of evidence synthesis that aims to systematically identify and map the breadth of evidence available on a particular topic, field, concept, or issue, often irrespective of source (i.e., primary research, reviews, non-empirical evidence) within or across particular contexts” [4].

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis found no current or historic systematic reviews or scoping reviews on this topic. This evaluation of the current guidance on the management of caries in CYP forms part of a package of work to inform the development of a position statement and nationally agreed curricula on caries management teaching for undergraduate students within UK dental schools.

This scoping review identifies and appraises the quality of clinical guidelines relevant to the management of caries in CYP and maps their recommendations. This will inform the development of a consensus on the curricula for teaching caries management to undergraduate Dentistry and Dental Hygiene and Therapy students at UK dental schools.

Aim and objectives

The aim of the review was to evaluate current guidelines for caries management in CYP to inform undergraduate dental education in the UK.

The specific objectives were to:

• 1. Identify guidelines relevant to the management of caries in CYP;

• 2. Appraise the quality of the guidelines using the AGREE II tool;

• 3. Synthesise recommendations from relevant guidelines of acceptable quality to guide undergraduate teaching of caries management in CYP in the UK; and

• 4. Identify gaps in the current guidelines regarding the management of caries in CYP.

Methods

The protocol for this scoping review was registered prospectively on 27/03/23 on Open Science Framework (https://doi.org/10.17605/OSF.IO/SBHC3). The review was reported according to PRISMA-ScR (see supplementary material) [19].

Eligibility

Inclusion criteria

To be included, the publication must:

• Be a clinical guideline;

• Contain information on the management of dental caries in CYP;

• Have been developed using a structured guideline methodology;

• Provide recommendations on the management of dental caries in children and/or young people;

• Be endorsed or created by a recognised dental organisation;

• Be written by multiple authors; and,

• Be published from 2007 onwards.

Guidelines from any country, relating to any dental setting (primary, secondary, or tertiary care) and written in English (these were considered likely to be most relevant to the UK setting) were considered. Studies published since 2007 were included as this was when the first clinical trial of the Hall Technique was published [20]. This is generally considered a time when an institutional shift in the thinking behind caries management, towards biological management of caries, began to occur.

The definition of, and ages at which people are considered to be, children and young people vary internationally therefore any publication that used the term children and or young people was included to ensure relevant publications were not excluded based on this point.

Exclusion criteria

Expert opinion papers, position statements and guidelines produced by industry were not considered for inclusion.

Types of sources

Only guidelines, or conference proceedings subsequently published as guidelines, endorsed or created by recognised dental organisations were considered.

Selection of sources of evidence

The search strategy aimed to locate both published and unpublished guidelines. An initial limited search of MEDLINE via PubMed was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a comprehensive search strategy (Appendix 1). This search strategy, including all identified keywords and index terms, was adapted for each included database and information source.

The databases searched included Cochrane Library, MEDLINE via PubMed, TRIP Medical Database and Web of Science. Sources of unpublished guidelines/grey literature were searched by contacting authors of existing guidelines to find out whether they were aware of any others underway. Webpages of major dental organisations in this field known to the authors were also searched, alongside a hand search of conference proceedings and a Google Web Search™ (Google LLC, California, United States of America). The reference lists of all included sources of evidence were screened for additional studies.

Search strategy

The search (Fig. 1) was conducted for guidelines published between 01/01/2007 and 21/04/2023. The TRIP database search was further modified to include “guidance” as “guidelines” yielded only five results. The search was repeated on 25/01/2024 and no new guidelines were identified that met the criteria for this review.

Selection of guidelines

Results from databases were screened independently and concurrently by two reviewers (FC and NI) against the inclusion criteria using Rayyan© software (Rayyan, Massachusetts, United States of America) [21]. Hand searching was conducted by one researcher (FC). All findings were compiled into a Microsoft® Excel® (Microsoft® Corporation, Washington, United States of America) spreadsheet (Appendix 2). Full texts were obtained, and reviewers met to discuss any disagreement for both database and hand searching.

Guideline selection was guided by the minimum score of 4.5 in the overall AGREE II scoring indicating quality standard (Table 1), but reviewers also included wider considerations relating to the relevance to the UK education and wider paediatric dentistry environment as well as the paediatric caries-specific curriculum.

Table 1 Domains covered by the AGREE II quality appraisal tool (AGREE II)

Data extraction and charting

Guidelines initially considered to meet the inclusion criteria were distributed between two teams of three reviewers for independent, duplicate data extraction (calibrated through data extraction and discussion of one guideline) with discussion to achieve a single agreed dataset. Microsoft® Forms® (Microsoft® Corporation, Washington, United States of America) was used for data extraction (Appendix 3) and quality appraisal.

Quality appraisal

Quality appraisal was undertaken by each reviewer within the same two teams alongside data extraction using the AGREE II criteria [22]. Table 1 details the AGREE II tool and the domains covered. Calibration was undertaken alongside calibration for data extraction. Reviewers were blinded and quality appraisal was undertaken using Microsoft Forms® (Microsoft® Corporation, Washington, United States of America). Any disagreements were discussed, and a consensus reached for each domain.

Synthesis of results

Results were collated by one reviewer in Microsoft® Excel® (Microsoft® Corporation, Washington, United States of America). Reviewers met to discuss any conflicts and agree the final dataset.

Data from each guideline were tabulated and summarised in categories relating to the specific area of caries management including depth of lesion and primary/permanent dentition.

Results

The results of the search, screening and agreement for guidelines published between 1/1/07 and 25/01/2024 is shown in Fig. 1.

Fig. 1

Flow diagram of databases searched, findings and outputs

Of the 581 guidelines identified from the search, there were 16 guidelines meeting the eligibility and quality criteria for inclusion. Table 2 shows the characteristics of the guidelines and Table 3 the quality was appraised (Table 3).

Table 2 Characteristics of the identified guidelines that met the eligibility criteria for this scoping review and were taken forward for narrative synthesis (study demographics)

Table 3 Summary of guideline recommendations and AGREE II scores (n = 16 guidelines)

There were eight guidelines meeting the set quality standard and considered appropriate for inclusion, for which data extraction and synthesis were carried out (Tables 4 and 5).

Table 4 Synthesis of the guideline recommendations for primary teeth on management of carious lesions

Table 5 Synthesis of guideline recommendations for permanent teeth

Discussion

Based on guideline quality indicators and relevance to education on the management of dental caries in CYP within the UK setting, eight guidelines were selected for synthesis of their clinical recommendations. The review was carried out to provide an evidence-base to inform the development of a consensus for the undergraduate curriculum for caries management in CYP, specific to the UK. The need for this consensus was highlighted by a UK survey evaluating current teaching practices for caries management in children and young adults, which showed great variance in the content of teaching and a delay in modernising curricula to keep up with best available evidence [3].

Initial screening identified 16 guidelines but following quality appraisal using the AGREE II tool, only eight were suitable for inclusion in the data synthesis. The exclusion of nine of the 16 guidelines demonstrates the constant problem with quality of evidence and waste [23]. In this case, the quality issues surrounded the development and reporting of guidelines. One of the most common reasons for exclusion of guidelines from synthesis in this study related to the lack of detail and transparency around the process for development of the guidelines, meaning that quality for inclusion could not be adequately determined. These guidelines did not have listed authors to contact to clarify this for inclusion.

Biological caries management approaches

Preformed metal crowns are recommended in all guidance for the restoration of multi-surface carious lesions. However, in UK guidance, it is specified that preformed metal crowns, placed using the Hall Technique, are the treatment of choice for managing lesions that require intervention but no pulpal therapy [5].

Non-restorative cavity control, is “the approach to make the cavitated caries lesions accessible to tooth cleaning by removal of overhanging enamel margins” [24]. This is suggested as an option for management of caries over 1/3 into dentine in primary teeth by SDCEP guidance [5]. There is poor evidence on the suitability of this option and the authors would be reluctant to suggest this other than the rare situation when no other treatment is possible, the child is co-operative for this treatment alone, and excellent oral hygiene and dietary practices are in place at home.

The use of SDF in practice alongside restorative options especially Atraumatic Restorative Technique (ART), have been, referred to as the SMART (Silver Modified ART) or SMART Hall where the Hall Technique is used following SDF application [25]. No guideline discussed this, but it is a recent technique and there is very little evidence apart from case reports and some very recent clinical trial work [26].

Key themes from these guidelines include the move to selective caries removal and avoidance of complete caries removal unless in specific circumstances in anterior teeth only [3]. For “early lesions” in primary and permanent teeth with and without cavitation, several guidelines recommend biological management including site specific prevention and fissure sealants [5, 14, 27].

Pulp therapy

In the guidelines, pulpotomy was recommended in primary teeth with a carious exposure in some circumstances, with pulpectomy only being recommended in exceptional circumstances for restorable teeth. Interestingly, within the context of the UK, pulp therapy is rarely undertaken in a primary care setting. A recent survey of general dentists in Scotland found that 91% do not offer vital pulp therapy to adult patients due to constraints such as their working contract and costs of materials [28]. Although this survey explored adult treatment it would be unlikely that this group of dentists offers vital pulp treatment to children and not adults, if cost and materials are being cited as barriers. Whilst undergraduate teaching for dentists and therapists in many UK dental schools still include pulp therapy, patients would typically be referred to a clinician with enhanced skills if this approach was required, in accordance with commissioning guidance [3, 29]. As such, there is a need to gain a consensus on whether these recommendations should be taken forward in the development of a paediatric caries curriculum for undergraduate dental and therapy students in the UK, or whether these techniques should instead be taught as an advanced skill at postgraduate level [3, 29].

For permanent teeth with caries into pulp, a partial pulpotomy was recommended in one guideline [12]. This is an evolving area of research with a current randomised control trial underway in the UK to contribute to the evidence base on pulpotomy versus root canal treatment in primary care [28].

Regenerative endodontic treatments were supported by one guideline [12]. This was based on evidence from a position statement by the American Association of Endodontics and a ‘Colleagues for Excellence’ guide, with no precise indications for this option other than immature teeth with pulp necrosis [30, 31]. Most evidence surrounding regenerative endodontics relates to traumatic dental injuries. Although both dental trauma and dental caries, can result in a loss of pulp vitality, the nature of the resulting infection is likely to be different, as may be the prognosis following this procedure.

Materials

Amalgam

One US based guideline states that amalgam is not recommended except in some cases when a tooth is anticipated to exfoliate within two years [12] but has limited applicability for UK dental schools working within regulations, such as the EU directive outlawing the use of amalgam in children under 15 except when unavoidable [32]. No guidelines developed within Europe advocate the use of amalgam in CYP. This contrasts with current practice in the UK, shown in findings from the aforementioned evaluation of paediatric caries management teaching practices [3].

GIC

Glass ionomer cement definitive restorations are advised against by some guidelines [14]. This continues to be a contentious issue, with the type of glass ionomer cement probably the most important factor in its success [33].

Resin-based materials

Given the restrictions on use of amalgam and the limitations of GIC, there is an increasing reliance on use of resin-based composite materials for definitive restorations. As such, it is unsurprising that these materials were advocated in all included guidelines. This was in particular the AAPD Pediatric Restorative Dentistry and SDCEP Prevention and Management of Dental Caries in Children documents, due to composite’s comparable success to amalgam [5, 14].

Evidence gaps

Gaps in evidence were identified within the guidelines, for example, on how to manage early cavitated carious lesions of minimal depth which would require complete caries removal solely for the purposes of providing adequate depth for a retentive restoration [1]. These gaps may have been addressed in some of the guidelines we did not include. Nevertheless, they are omitted from otherwise comprehensive and high-quality guidelines.

The variability in terminology, for example, continued use of non-specific terms such as “early lesions” and use of Interim Therapeutic Restoration in US-based documents in place of Atraumatic Restorative Treatment, indicate there is a still no widespread adoption of international consensus on terminology [24].

None of the guidelines recommended tooth tissue removal for early carious lesions, in stark contrast with current teaching practices in the UK [3].

In part, because of inappropriate and inexact use of terminology, none of the guidelines specifically defined carious lesions limited to enamel, how these should be classified and therefore this poses a challenge in selecting the most appropriate treatment option as some clinical judgement is required on accurate diagnosis.

Another challenge not addressed by the guidelines is monitoring caries lesion transition, which is recommended by some guidelines, without specific detail on how [5, 16, 34]. Current record keeping only allows for gross scoring of the presence or absence of carious lesions on a surface, so it is not possible to tell whether lesions have progressed over time. The International Caries Detection and Assessment System (ICDAS) or photographs may help with this but are rarely used and there is no evidence on their accuracy in monitoring progression.

Context and relevance

This scoping review, undertaken to inform consensus discussions for the development of a UK undergraduate curriculum for caries management in CYP, has identified gaps in guidelines including the classification of early carious lesions and how early cavitated lesions should be managed for CYP. These key findings must be considered in discussions with stakeholders in the UK, with consideration of the findings of preceding work that evaluated the current teaching of caries management in CYP [3]. Areas for exploration in consensus discussions include total integration of biological caries management, selective caries removal and the consideration of whether a pulpotomy for the management of caries is a specialist treatment that requires onward referral.

Furthermore, is important to note that UK dental schools currently provide teaching for students due to graduate and work largely within the National Health Service. There is an expectation that further postgraduate training would be required for delivery of more specialist level procedures. This is in part, related to current UK remuneration systems and possibly the lack of suitable guidelines for incorporation in teaching. As such, students are unlikely to be taught some of the techniques that are mentioned in recommendations in these guidelines, such as use of non-fluoride-based remineralisation agents, resin infiltration for proximal carious lesions, or regenerative endodontic treatments. Further discussion on whether these approaches should be included in a new curriculum would be warranted.

These findings are relevant to those involved in undergraduate teaching of paediatric dentistry, those who develop undergraduate curricula and policymakers.

Strengths and limitations

Rigorous methodology was used when undertaking this review. This involved blinded screening for eligibility, the assessment of the quality of each guideline using the AGREE II tool and independent review of each guideline by at least two researchers. Meetings were held for agreement and discussing results. Authors of relevant guidelines were also contacted for clarity and to ensure the inclusion of relevant sources. Limitations include the possibility of missed literature in the grey literature search, although every effort was made to find relevant guidelines. There was a lack of high quality, methodologically transparent guidance. Although initially 16 guidelines were eligible for inclusion, assessment of quality using the AGREE II tool meant that only eight guidelines were suitably rigorous to include in the analysis. There were also instances of contradictory recommendations.

Conclusions

This scoping review identified a limited number of high-quality guidelines suitable for shaping a UK undergraduate dental curriculum in caries management for CYP. However, there were guidelines of sufficient quality for data synthesis generally supportive of biological approaches, which is largely contradictory to current UK undergraduate teaching. There were some gaps in evidence that need to be addressed in future research and guideline development. The evidence synthesised from this review will be used as the basis for deriving a consensus on the content of a new undergraduate curriculum for paediatric caries management.