International consensus on fluoride programmes for Early Childhood Caries prevention in early education settings: A systematic overview and Delphi approach

Abstract
Objectives: (1) to assess and develop international expert consensus on the evidence for fluoride-based interventions (FBI) in early-year education settings (EyE-settings; (kindergartens/nursery and primary schools) for reducing Early Childhood Caries (ECC) and (2) to synthesise clear programme-level recommendations with regard to ECC pre-vention in this setting. Basic research design: A systematic overview of systematic reviews, trials, and observational studies was performed to identify and critically ap-praise the available evidence on the effectiveness and cost-effectiveness of FBI in EyE-settings to prevent ECC. This was followed by a three-stage modified Delphi ex-ercise. Participants: The Delphi panel (21 experts). Main outcome measures: Delphi round 1 online survey: opinions on FBI’s safety, effectiveness and feasibility; Delphi round 2, an iterative survey: group opinions and gather feedback on review findings. Consensus developed via in-depth, recorded group discussions during an online work-shop. Results: There was high-quality evidence and consensus that delivering super-vised toothbrushing in EyE-settings is safe and cost-effective, shows greater benefit to disadvantaged children, and is feasible in high and low/middle-income countries. There was more moderate support for the effectiveness and cost-effectiveness of fluo-ride varnish application in EyE-setting (especially where supervised toothbrushing with fluoridated toothpaste is in place). It was agreed that policy-makers should priori-tise at-risk groups where resources are limited. Conclusion: The systematic overview revealed that supervised toothbrushing with fluoridated toothpaste is the most effective, cost-effective, feasible and safest mechanism of caries prevention for children in EyE-settings. Panel consensus is that universal coverage of toothbrushing in EyE-settings is preferred but where resources are limited targeting based on need is indicated.