International consensus on fluoride programmes for early childhood caries prevention in early education settings: A systematic overview and Delphi approach

<b>Objectives:</b> (1) To assess and develop international expert consensus on the evidence for fluoride-based interventions 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 to prevent ECC in this setting. <i>Basic research design</i>: Systematic overview of systematic reviews, trials, and observational studies to identify and appraise the available evidence on the effectiveness and cost-effectiveness of fluoride-based interventions in EyE-settings. This was followed by a three-stage modified Delphi exercise. <i>Participants:</i> Delphi panel of 21 experts. <i>Main outcomemeasures</i>: Delphi round 1 online survey: opinions on fluoride-based interventions' 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 workshop. <b>Results:</b> There was high-quality evidence and consensus that supervised 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 fluoride varnish application in EyE-settings (especially where supervised toothbrushing with fluoridated toothpaste is in place). It was agreed that policy-makers should prioritise at-risk groups where resources are limited. <b>Conclusion:</b> Supervised toothbrushing with fluoridated toothpaste is the most effective, cost-effective, feasible and safest mechanism of caries prevention for children in EyE-settings. Universal coverage of toothbrushing in EyE-settings is preferred but targeting to need is indicated where resources are limited.