Developing clinical practice guidelines for caries prevention and management for pre-school children through the ADAPTE process and Delphi consensus

Lee et al. Health Research Policy and Systems (2016) 14:44 DOI 10.1186/s12961-016-0117-0 RESEARCH Open Access Developing clinical practice guidelines for caries prevention and management for pre-school children through the ADAPTE process and Delphi consensus Gillian H. M. Lee1*, Colman McGrath2 and Cynthia K. Y. Yiu1 Abstract Background: This study aims to develop consensus evidence-based clinical guidelines for caries prevention and management by caries risk assessment for pre-school children in Hong Kong. Methods: Employing the ADAPTE process, guidelines for caries prevention and management by caries risk assessment for pre-school children with a preliminary list of 91 recommendations was complied. External review of the guidelines was conducted by a panel of 41 reviewers from the Hong Kong Society of Paediatric Dentistry using a two-round web-based Delphi process. The reviewers were invited to contribute any comments on the draft-adapted guidelines and rated their agreement with each recommendation using a 9-point Likert scale. During the second round, 36 participants received anonymous feedback from the first round and assessed a narrowed list of 28 recommendations. Recommendations were retained and classified according to the median score and rating percentages by the reviewers. Results: A total of 70 out of 91 recommendations were retained (five reached high consensus, 65 reached consensus), and 21 recommendations were discarded. Recommendations and guidelines were outlined. Conclusions: Caries prevention and management guidelines for pre-school children were developed for use in Hong Kong using the ADAPTE process and Delphi consensus to develop evidence-based recommendations. This can facilitate the translation of guidelines into dental practice. Keywords: Guidelines, Guidelines development, ADAPTE, Delphi consensus, Oral health, Children, Caries risk assessment, Dental caries, Prevention Background Dental caries in pre-school children remains a problem in Hong Kong. In a recent population-based oral health survey, the caries experience of pre-school children was over 50% in Hong Kong, with an extensive proportion of untreated carious teeth (over 90%) [1]. One in 20 of the children had a dental abscess associated with an extensively decayed tooth. The prevalence of dental caries among pre-school children showed limited improvement over the past decade and the extent and severity have * Correspondence: 1 Paediatric Dentistry, Faculty of Dentistry, University of Hong Kong, 2/F, Prince Philip Dental Hospital, 34 Hospital Road, Hong Kong, China Full list of author information is available at the end of the article increased. Among pre-school children, the number of decayed, missing and filled teeth was 2.3 in 2001 and 2.5 in 2011 [1, 2]. Children from disadvantaged and socially marginalised populations have even higher caries experience and are at higher risk for caries. The high degree of untreated dental caries indicates that there is inadequate access to quality oral healthcare for pre-school children in Hong Kong. Management of pre-school children’s oral health requires commitment from professionals, patients and their families. Dentists’ attitudes can contribute to the problem, resulting in a barrier to provide adequate and quality dental care [3]. Dentists in Hong Kong do see the value of dental treatment for pre-school children, but most general dental practitioners consider children’s coping skills to dental © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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. Lee et al. Health Research Policy and Systems (2016) 14:44 treatment as a problem and have a negative attitude towards the provision of dental care for children [4]. A wide variation in caries management approaches among dental practitioners has also been identified [5], reflecting the uncertainty within the profession about the most suitable and effective dental care approaches for preschool children with dental caries. Thus, these factors highlight the need for clinical guidelines relating to dental caries for pre-school children in Hong Kong. Clinical practice guidelines are systematically developed statements that can assist practitioners and patients in making decisions about appropriate healthcare for specific clinical circumstances [6, 7]. It is the major available tool to assist in the translating of research evidence into practice. With the best available evidence and opinion in guidelines, healthcare professionals can be assisted in making appropriate clinical decisions, minimising variation in practice, and promote effective and safe patient outcomes. Expectations and requirements have been proposed internationally for the development of quality clinical guidelines [8, 9]. The development and implementation of guidelines that meet international standards require substantial time, expertise and resources, especially during systematic identification and critical analysis of evidence. Guideline adaptation is a systematic approach for considering the endorsement or modification of guidelines produced in one setting for application and implementation in another as an alternative to de novo guideline development or as a first step in the process of implementation, while preserving evidence-based principles [10]. The ADAPTE process is a comprehensive framework for guideline adaptation. ADAPTE can reduce duplication of effort and enhance efficiency in guideline development. The manual and toolkit for the ADAPTE process are available at: http://www.g-i-n.net/ gin [11]. The ADAPTE process consists of three main phases: set up, adaptation and finalisation. The Delphi technique is a formal iterative structured process that aims to gather consensus of opinion, judgement or choice among a panel of experts [12–15]. The attitudes, needs and priorities of the panel can be explored during the interactive process. Delphi is suitable for reaching consensus on topics with dissenting opinions, uncertainty or absence of evidence. Guidelines developed with consensus of stakeholders are more likely to be accepted by the dental profession. There are several quality guidelines for managing dental caries for pre-school children worldwide. Nevertheless, guidelines ascribed to other countries or areas can encounter barriers to their practical application in a context with a different culture and healthcare system [16]. Localised or adapted clinical guidelines on (...truncated)