Table 3 Final recommendations and their priority after two rounds of scoring based on RAND-UCLA appropriateness method

Diagnosis

Diagnostic tool

1. The reduced Cariogram software (without saliva tests), or the CAMBRA form (in the absence of the reduced Cariogram software) is recommended for caries risk assessment in adults [11,12,13, 44]

1

–

Preventive measure

Fluoride concentration of toothpaste

2. For low-risk adults, toothbrushing twice a day, using over the counter fluoride toothpastes (1000–1450 ppm F) is recommended [9, 20, 42, 44, 45, 48, 58, 68,69,70,71]

1

Malaysian

CAMBRA

CariesCare

ICCMS

CMS

3. For medium-risk adults, toothbrushing twice a day, using over the counter fluoride toothpastes (1000–1450 ppm F) is recommended [20, 42, 44, 45, 48, 58, 68,69,70,71]

1

Malaysian

CAMBRA

CariesCare

CMS

4. For high-risk adults, toothbrushing twice a day, using high fluoride toothpastes (1450 ppm F or more) is recommended [42, 44, 45, 72,73,74,75]

1

Malaysian

CariesCare

ICCMS

5. For extreme-risk adults, toothbrushing twice a day, using high fluoride toothpastes (1450 ppm F or more) is recommended [42, 44, 45, 72,73,74,75]

1

Malaysian

CariesCare

ICCMS

Sodium fluoride mouthrinse

6. For low-risk adults, use of NaF mouthrinse is not recommended [9, 18, 20, 48, 58, 68, 76, 77]

1

CAMBRA

ICCMS

CMS

7. For medium-risk adults, daily use of 220 ppm NaF mouthrinse or weekly use of 900 ppm NaF mouthrinse, at a time other than brushing and with 1 min duration, is recommended [9, 18, 20, 48, 58, 68, 76, 77]

1

CAMBRA

ICCMS

CMS

8. For high-risk adults, daily use of 220 ppm NaF mouthrinse or weekly use of 900 ppm NaF mouthrinse, at a time other than brushing and with 1 min duration, is recommended [9, 18, 20, 48, 58, 68, 76, 77]

1

ICCMS²

9. For extreme-risk adults, daily use of 220 ppm NaF mouthrinse or weekly use of 900 ppm NaF mouthrinse, at a time other than brushing and with 1 min duration, is recommended [9, 18, 20, 48, 58, 68, 76, 77]

1

ICCMS²

Chlorhexidine mouthrinse

10. For low-risk adults, use of chlorhexidine mouthrinse is not recommended [20, 48, 58]

1

CAMBRA

CMS

11. For medium-risk adults, use of chlorhexidine mouthrinse is not recommended [20, 48, 58]

1

CAMBRA

CMS

12. For high-risk adults, daily use of %0.12 chlorhexidine gluconate mouthrinse for 1 week in each month, at least 1 h apart from tooth brushing and with 1 min duration, is recommended [20, 48, 58]

1

CAMBRA

13. For extreme-risk adults, daily use of %0.12 chlorhexidine gluconate mouthrinse for 1 week in each month, at least 1 h apart from tooth brushing and with 1 min duration, is recommended [20, 32, 48, 58]

1

CAMBRA

CMS

Fluoride varnish

14. For low-risk adults, routine application of fluoride varnish is not recommended [20, 48, 58]

1

CAMBRA

15. For medium-risk adults, application of fluoride varnish, every 6 months, is recommended [18, 59, 77, 78]

1

ICCMS

16. For high-risk adults, application of fluoride varnish, every 4–6 months, is recommended [18, 20, 48, 58, 59, 77, 78]

1

CAMBRA

ICCMS

17. For extreme-risk adults, application of fluoride varnish, every 3–4 months, is recommended [18, 20, 48, 58, 59, 77, 78]

1

CAMBRA

ICCMS

In office fluoride gel³

18. For low-risk adults, routine application of NaF gel is not recommended [18, 50, 77]

1

ICCMS

19. For medium-risk adults, application of %2 NaF gel at office is recommended [18, 50, 77]

2

ICCMS

20. For high-risk adults, application of %2 NaF gel at office is recommended [18, 50, 77]

1

ICCMS

21. For extreme-risk adults, application of % NaF gel at office is recommended [18, 50, 77]

1

ICCMS

At home fluoride gel

22. For extreme-risk adults, in case of caries progression despite receiving toothpaste, mouthrinse and varnish, daily application of 5000 ppm fluoride gel by at-home trays, with 5-min duration, is recommended [20, 48, 58]

1

CAMBRA

Mouth buffering

23. For extreme-risk adults, ad libitum rinsing of the mouth with water and baking soda (2 tea spoons in 250 ml water) is recommended [20, 48, 58, 79]

1

CAMBRA

Pit and fissure sealants

24. For medium-risk adults, sealant application in caries-prone areas is recommended [17, 33, 55, 80,81,82]

4

CariesCare

ICCMS

25. For high-risk adults, sealant application in caries-prone areas is recommended [17, 33, 55, 80,81,82]

1

CariesCare

ICCMS

26. For extreme-risk adults, sealant application in caries-prone areas is recommended [17, 33, 55, 80,81,82]

1

CariesCare

ICCMS

Operative treatment threshold

ICDAS 1,2 occlusal lesions

(Incipient caries without dentine involvement or obvious cavity)

27. For low-risk adults, ICDAS 1,2 occlusal lesions (incipient caries without dentine involvement or obvious cavity), if are active, should be managed non-operatively and if are inactive, should be assessed at follow-up sessions for any changes [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

28. For medium-risk adults, ICDAS 1,2 occlusal lesions if are active, should be managed non-operatively and if are inactive, should be assessed at follow-up sessions for any changes [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

29. For high-risk adults, ICDAS 1,2 occlusal lesions, if are active, should be managed non-operatively and if are inactive, should be assessed in follow-up sessions for any change [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

30. For extreme-risk adults, ICDAS 1,2 occlusal lesions, if are active, should be managed non-operatively and if are inactive, should be assessed at follow-up sessions for any changes [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

ICDAS 3 occlusal lesions

(Enamel micro-cavities without an underlying dentin shadow)

31. For low-risk adults, ICDAS 3 occlusal lesions can be managed non-operatively [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

32. For medium-risk adults, ICDAS 3 occlusal lesions can be managed non-operatively [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

33. For high-risk adults, ICDAS 3 occlusal lesions can be managed non-operatively [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

34. For extreme-risk adults, ICDAS 3 occlusal lesions can be managed non-operatively (33, 53–56, 81–85)

4

CariesCare

CMS

ICDAS 4 occlusal lesions

(Enamel micro-cavities with an underlying dentin shadow)

35. For low-risk adults, ICDAS 4 occlusal lesions can be managed non-operatively, only if the lesion is inactive and the radiolucency does not engage the whole outer third of dentine [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

36. For medium-risk adults, ICDAS 4 occlusal lesions should be managed operatively [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

37. For high-risk adults, ICDAS 4 occlusal lesions should be managed operatively [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

38. For extreme-risk adults, ICDAS 4 occlusal lesions should be managed operatively [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

C1, C2 proximal lesions

(Outer half and inner half of enamel)

39. For low-risk adults, C1, C2 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

40. For medium-risk adults, C1, C2 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

41. For high-risk adults, C1, C2 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended [33, 53,54,55,56, 81,82,83,84,85]

2

CariesCare

CMS

42. For extreme-risk adults, C1, C2 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended [33, 53,54,55,56, 81,82,83,84,85]

2

CariesCare

CMS

C3 proximal lesions

(Just into dentinoenamel junction)

43. For low-risk adults, C3 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended [33, 53,54,55,56, 81,82,83,84,85]

4

CariesCare

CMS

44. For medium-risk adults, C3 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended [33, 53,54,55,56, 81,82,83,84,85]

4

CariesCare

CMS

45. For high-risk adults, operative management of C3 proximal lesions is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

46. For extreme-risk adults, operative management of C3 proximal lesions is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

C4 proximal lesions

(Outer third of dentin

47. For low-risk adults, C4 proximal lesions do not need restoration, application of topical fluoride and follow-up is recommended only if the radiolucency does not engage the whole outer third of dentine and there is no cavity after teeth separation. Otherwise, operative management is recommended [33, 53,54,55,56, 81,82,83,84,85]

4

CariesCare

CMS

48. For medium-risk adults, operative management of C4 proximal lesions is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

49. For high-risk adults, operative management of C4 proximal lesions is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

50. For extreme-risk adults, operative management of C4 proximal lesions is recommended [33, 53,54,55,56, 81,82,83,84,85]

1

CariesCare

CMS

Follow up

Follow up interval

51. For low-risk adults, 12 months follow-up interval is recommended [20, 48, 57,58,59, 86]

1

CAMBRA

52. For medium-risk adults, 6 months follow-up interval is recommended [20, 48, 57,58,59, 86]

1

Malaysian

CAMBRA

CMS

53. For high-risk adults, 4–6 months follow-up interval is recommended [20, 48, 57,58,59, 86]

1

CAMBRA

54. For extreme-risk adults, 3–4 months follow-up interval is recommended [20, 48, 57,58,59, 86]

1

CAMBRA

CMS