Preventing Dental Caries in Children

Preventing Dental Caries in Children ,5 Years:Systematic Review Updating USPSTF Recommendation

abstractBACKGROUND AND OBJECTIVE: Screening and preventive interventionsby primary care providers could improve outcomes related to earlychildhood caries. The objective of this study was to update the 2004US Preventive Services Task Force systematic review on prevention ofcaries in children younger than 5 years of age.

METHODS: Searching Medline and the Cochrane Library (throughMarch 2013) and reference lists, we included trials and controlled ob-servational studies on the effectiveness and harms of screening andtreatments. One author extracted study characteristics and results,which were checked for accuracy by a second author. Two authors in-dependently assessed study quality.

RESULTS: No study evaluated effects of screening by primary care pro-viders on clinical outcomes. One good-quality cohort study foundpediatrician examination associated with a sensitivity of 0.76 foridentifying a child with cavities. No new trials evaluated oral fluoridesupplementation. Three new randomized trials were consistent withprevious studies in finding fluoride varnish more effective than novarnish (reduction in caries increment 18% to 59%). Three trials ofxylitol were inconclusive regarding effects on caries. New observationalstudies were consistent with previous evidence showing an associationbetween early childhood fluoride use and enamel fluorosis. Evidence onthe accuracy of risk prediction instruments in primary care settings isnot available.

CONCLUSIONS: There is no direct evidence that screening by primarycare clinicians reduces early childhood caries. Evidence previouslyreviewed by the US Preventive Services Task Force found oral fluoridesupplementation effective at reducing caries incidence, and new evi-dence supports the effectiveness of fluoride varnish in higher-riskchildren. Pediatrics 2013;132:332–350

AUTHORS: Roger Chou, MD,a,b,c Amy Cantor, MD, MHS,a,d

Bernadette Zakher, MBBS,a Jennifer Priest Mitchell, BA,a

and Miranda Pappas, MAa

aPacific Northwest Evidence-Based Practice Center, OregonHealth & Science University, Portland, Oregon; and Departmentsof bMedicine, cMedical Informatics and Clinical Epidemiology, anddFamily Medicine and Obstetrics/Gynecology, Oregon Health &Science University, Portland, Oregon

KEY WORDSDental caries, children, screening, treatment, prevention,fluoride, fluorosis, xylitol, education, counseling

ABBREVIATIONSdmfs—decayed, missing, or filled tooth surfacesOR—odds ratioUSPSTF—US Preventive Services Task Force

All authors made substantial contributions to conception anddesign, acquisition of data, and analysis and interpretation ofdata, and gave final approval of the version to be published. DrChou drafted the article and revised it critically for importantintellectual content. He is guarantor for this article. Drs Cantor,Zakher, Mitchell, and Pappas revised the article critically forimportant intellectual content.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-1469

doi:10.1542/peds.2013-1469

Accepted for publication May 16, 2013

Address correspondence to Roger Chou, MD, Pacific NorthwestEvidence-Based Practice Center, Oregon Health & ScienceUniversity, Mail Code: BICC, 3181 SW Sam Jackson Park Rd,Portland, OR 97239. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: Supported by the Agency for Healthcare Research andQuality (AHRQ) for the US Preventive Services Task Force underContract No. 290-2007-10057-I to support the work of the USPSTF.Staff at AHRQ and members of the USPSTF developed the scopeof the work and reviewed draft manuscripts. Approval fromAHRQ was required before the manuscript was submitted forpublication, but the authors are solely responsible for thecontent and the decision to submit it for publication.

332 CHOU et al

mailto:[email protected]

Dental caries is an infectious processinvolvingbreakdownof the toothenamel.1,2

It is the most common chronic diseaseof children in the United States, and is in-creasing in prevalence among 2- to 5-year-olds.3–5 Approximately three-quarters ofchildren with caries have not receivedtreatment.5

Early childhood caries is associatedwith pain and tooth loss, as well asimpaired growth, decreased weightgain, and negative effects on speech,appearance, self-esteem, school per-formance, and quality of life.2,6,7 Dentalcaries disproportionately affects mi-nority and economically disadvantagedchildren.5 Risk factors for dental cariesinclude high levels of colonization bycariogenic bacteria, frequent exposureto dietary sugar and refined carbohy-drates, inappropriate bottle feeding,low saliva flow rates, developmentaldefects of tooth enamel, previous car-ies, lack of access to dental care, lowcommunity water fluoride levels, in-adequate tooth brushing or use offluoride-containing toothpastes, lackof parental knowledge regarding oralhealth, and maternal risk factors, in-cluding caries, high levels of cariogen-ic bacteria, or poor maternal oralhygiene.4,8,9

Screening for dental caries beforeschool entry could lead to interventionsto treat existing caries at an earlierstage and prevent future caries. Youngchildren often see a primary caremedical provider starting shortly afterbirth, but do not see a dentist until theyare older, suggesting an importantprimary care role for caries pre-vention.10,11 Access to dental care islimited by many factors, including lackof dental coverage and shortages indentists treating young children, par-ticularly those who are uninsured orpublicly insured.12,13 Once childrenenter school, there are additionalopportunities for screening and treat-ment.14

In 2004, the US Preventive Services TaskForce (USPSTF) recommended thatprimary care clinicians prescribedietary fluoride supplementation tochildren .6 months of age whoseprimary water source is deficient influoride (B recommendation).15 TheUSPSTF found insufficient evidence torecommend for or against primarycare clinician risk assessment of+children ,5 years of age for theprevention of dental disease (I recom-mendation). The USPSTF found no validat-ed risk-assessment tools or algorithms

for assessing dental disease risk byprimary care clinicians, and little evi-dence on the accuracy of primary careclinicians in performing oral examina-tions or assessing dental caries risk.2

In addition, the USPSTF found little ev-idence on the effectiveness of parentaleducation or referring children at highrisk to dental care providers in re-ducing risk of caries and related dentaldisease.

AIMS OF THIS REVIEW

This report was commissioned by theUSPSTF to update its 2004 recommen-dation on dental caries prevention inchildren ,5 years of age.15 With theinput of members of the USPSTF,we developed an analytic framework(Fig 1) and key questions to guide ourliterature search and review:

1. How effective is oral screening (in-cluding risk assessment) by theprimary care clinician in prevent-ing dental caries in children ,5years of age?

2. How accurate is screening by theprimary care clinician in identify-ing children ,5 years of age who:

a. have cavitated or noncavitatedcaries lesions?

FIGURE 1Analytic framework.

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b. are at increased risk for futuredental caries?

3. What are the harms of oral healthscreening by the primary careclinician?

4. How effective is parental orcaregiver/guardian oral health ed-ucation by the primary care clini-cian in preventing dental caries inchildren ,5 years of age?

5. How effective is referral by a pri-mary care clinician to a dentistin preventing dental caries in chil-dren ,5 years of age?

6. How effective is preventive treat-ment (dietary fluoride supplemen-tation, topical fluoride application,or xylitol) in preventing dental car-ies in children ,5 years of age?

7. What are the harms of specific oralhealth interventions for preventionof dental caries in children,5 yearsof age (parental or caregiver/guardian oral health education, re-ferral to a dentist, and preventivetreatments)?

Key question 1 focuses on direct evi-dence on the effectiveness of oralscreening (including oral examinationand assessment of risk for futurecaries) by primary care clinicians inpreventing future dental caries andassociated complications, comparedwith not screening. Such direct evi-dence on the effectiveness of screeninginterventions is often limited. There-fore, the remainder of the analyticframework (key questions 2 through 7)evaluates the chain of indirect evidenceneeded to link screening with im-provement in important health out-comes. Links in the chain of indirectevidence include the accuracy ofscreening to identify children withcariesorat increasedriskofdevelopingcaries, the effectiveness of inter-ventions to reduce the incidence ofdental caries and associated compli-cations, and harms (including dental

fluorosis) associated with screeningand preventive treatments. Implicit inthe indirect chain of evidence is that,to understand benefits and harms ofscreening, it is not sufficient to showthat children at risk for dental cariescan be identified; it is also necessaryto show that there are effective treat-ments for those identified.

METHODS

This reviewwasconductedat thePacificNorthwest Evidence-Based PracticeCenter under contract with the Agencyfor Healthcare Research and Quality(Contract No. HHSA-290-2007-10057-I,Task Order No. 13), by using the sys-tematic review methods developed bythe USPSTF.16,17

Search Strategies

We searched Ovid Medline (January1999 to March 8, 2013) and theCochrane Library Database (throughthe first quarter of 2013) for relevantarticles, and reviewed reference listsfor additional citations. Search strat-egies are shown in Supplemental Ap-pendix 1.

Study Selection and Processes

Abstracts were selected for full-textreview if they included children ,5years old (including those with cariesat baseline), were relevant to a keyquestion, and met the predefined in-clusion criteria (Supplemental Ap-pendix 2). We restricted inclusion toEnglish-language articles and exclud-ed studies published only as abstracts.Studies of nonhuman subjects werealso excluded, and studies had to re-port original data.

We focused on studies of screening ordiagnostic accuracy performed inprimary care settings. For preventivetreatments (key question 6), we alsoincluded studies of primary care–feasible treatments (treatments that

could be administered or prescribedwithout requiring extensive dentaltraining) performed in non–primarycare settings. Treatment interventionswere parental or caregiver education,referral to a dentist by a primary careclinician, and preventive treatments,including dietary fluoride supplemen-tation, fluoride varnish, and xylitol.Interventions not commonly used oravailable in the United States (such aschlorhexidine varnish, povidone iodinerinses, and alternative methods forapplying topical fluoride) are dis-cussed in the full report,18 as arestudies that compared different dosesof xylitol. Outcomes included de-creased incidence of dental caries andassociated complications and harms,including dental fluorosis. Many stud-ies reported a composite caries out-come of the presence of 1 or moredecayed (noncavitated or cavitated),missing (due to caries), or filled toothsurfaces in preschool-age children.19

The abbreviation dmfs refers to de-cayed, missing, or filled primary toothsurfaces, and dmft refers to decayed,missing, or filled primary teeth (1 toothmay have more than 1 affected sur-face).

We included randomized controlledtrials,nonrandomizedcontrolledclinicaltrials, and cohort studies for all keyquestions. We also included an updatedsystematic review originally included inthe 2004 USPSTF review of observationalstudies on risk of enamel fluorosis.20,21

Community interventions for preventionof dental caries and school-based in-terventions for older children areaddressed elsewhere by the US Com-munity Services Task Force.22

At least 2 reviewers independentlyevaluated each study to determine in-clusion eligibility. One investigator ab-stracted details about each article’sstudy design, patient population, set-ting, screening method, treatment regi-men, analysis, follow-up, and results.

334 CHOU et al

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A second investigator reviewed dataabstraction for accuracy.

Quality Assessment and Synthesis

Two investigators independently appliedcriteria developed by the USPSTF16,17 torate the quality of each study as good,fair, or poor (Supplemental Appendix 3).Discrepancies were resolved througha consensus process. See Table 1 fora list of quality ratings for the includedrandomized trials. We assessed the ag-gregate internal validity (quality) of thebody of evidence for each key question(“good,” “fair,” “poor”) using methodsdeveloped by the USPSTF, based on thenumber, quality, and size of studies;consistency of results among studies;and directness of evidence.16,17 Meta-analysis was not attempted becauseof methodological shortcomings in thestudies and differences across studiesin design, interventions, populations,and other factors.

RESULTS

Our literature search identified a totalof 1215 citations, of which we reviewed539 full-text publications and included20 studies (Fig 2).

Benefits and Harms of Screening

No randomized trial or observationalstudy compared clinical outcomesbetween children ,5 years of agescreened and not screened by primarycare clinicians.

Accuracy of Oral Examination

One good-quality study found primarycare pediatrician examination ofMedicaid-eligible children,36 monthsof age (n = 258) after 2 hours of oralhealth education associated with asensitivity of 0.76 (19/25) for identifyinga child with 1 or more cavities and 0.63(17/27) for identifying children in needof a dental referral, compared with a pe-diatric dentist evaluation (Supplemental

Tables 5 and 6).41 Specificity was 0.95and 0.98, respectively. The need forreferral was determined by the pres-ence of a cavity, soft tissue pathology,or evidence of tooth or mouth trauma.A study included in the 2004 USPSTFreview found pediatrician examinationafter 4 hours of oral health educationassociated with a sensitivity of 1.0 andspecificity of 0.87 for identifying nurs-ing caries in children 18 to 36 monthsof age.42

Accuracy of Risk Assessment forFuture Dental Caries

Although risk assessment tools for useinprimarycaresettingsareavailable,43,44

we found no study on the accuracy ofrisk assessment by primary care clini-cians using these or other instruments.

Effectiveness of Oral HealthEducation

No trial specifically evaluated an edu-cational or counseling interventionby a primary care clinician to preventdental caries. Two nonrandomized tri-als (1 fairquality27 and1poorquality24,25)found multifactorial interventions thatincluded an educational componentwere associated with decreased car-ies outcomes in underserved children,5 years of age. Other componentsof the interventions included addi-tional pediatrician training, elec-tronic medical record reminders, andprovision of tooth-brushing materials.In addition to use of a nonrandomizeddesign, other methodological short-comings in the poor-quality study werehigh attrition and failure to adjust forconfounders.24,25

Effectiveness of Dental Referral

No study directly evaluated the effectsof referral by a primary care clinician toa dentist on caries incidence. A fair-quality retrospective cohort study (n= 14 389) found that having a firstdental preventive visit after 18 months

of age in Medicaid children withexisting dental disease was associ-ated with increased risk of subse-quent dental procedures comparedwith having a first visit before 18months of age (incidence density ratioranged from 1.1 to 1.4, depending ontime of first dental visit, after adjust-ing for gender, race, number of well-child visits, and other factors), butwas not designed to determine re-ferral source.45

Effectiveness of PreventiveTreatments

Dietary Fluoride Supplementation

We identified no trials published sincethe 2004 USPSTF review on effectsof dietary fluoride supplementation inchildren ,5 years of age. One ran-domized trial46 and 4 nonrandomizedtrials47–50 included in the 2004 USPSTFreview found dietary fluoride supple-mentation in settings with water fluo-ridation levels below 0.6 ppm Fassociated with decreased caries in-cidence versus no fluoridation (per-centage reduction in incidence rangedfrom 48% to 72% for primary teeth and51% to 81% for primary tooth surfa-ces).2 In the single randomized trial(n = 140, fluoridation ,0.1 ppm F),percent reductions in incidence rangedfrom 52% to 72% for teeth and 51% to81% for tooth surfaces, depending onwhetherfluoride was given as tablets ordrops.46 Two of the trials with extendedfollow-up also found dietary fluoridesupplementation associated with de-creased incidence of caries at 7 to 10years of age (reductions ranged from33% to 80%).47,51

Fluoride Varnish

Two good-quality28,31 and 1 fair-quality34

trials published since the 2004 USPSTFreview evaluated fluoride varnish(2.26% F) applied every 6 months ver-sus no fluoride varnish (Table 2).Sample sizes ranged from 280 to 1146

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TABLE 1 Quality Ratings of Randomized Controlled Trials

Author,Year, Title

RandomizationAdequate?

AllocationConcealmentAdequate?

Groups Similarat Baseline?

EligibilityCriteriaSpecified?

OutcomeAssessorsMasked?

CareProviderMasked?

PatientMasked?

Reporting ofAttrition,

Crossovers,Adherence,

andContamination

Loss ToFollow-up:Differential/

High

Intention-To-TreatAnalysis

PostrandomizationExclusions

OutcomesPrespecified

FundingSource

ExternalValidity

QualityRating

Alamoudi et al2012

23Unclear Yes Unclear Yes Unclear No No Yes Yes (very high) Yes Yes Yes The Deanship

of ScientificResearch, KingAbdulazizUniversity, Jeddah,Saudi Arabia(Project No. 429/011-9)

Fair Poor

Effects ofxylitol onsalivarymutansStreptococcus,plaque level,and cariesactivity ina group ofSaudi mother-child pairs

Davies et al 200724

Notrandomized

Unclear Yes Yes Unclear Unclear Unclear No Yes No No Yes National HealthService Researchand DevelopmentProgramfor PrimaryDental Care

Fair PoorChallengesassociated withthe evaluationof a dentalhealthpromotionprogram ina deprivedurban area

Davies et al 200525

A stagedinterventiondental healthpromotionprogram toreduce earlychildhoodcaries

Kovari et al 200326

NR NR Unclear Yes Unclear No No Yes No Yes No Yes Not reported Limited FairUse of xylitolchewing gum indaycarecenters:a follow-upstudy inSavonlinna,Finland

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TABLE 1 Continued

Author,Year, Title






CareProviderMasked?

PatientMasked?



andContamination


High




FundingSource

ExternalValidity

QualityRating

Kressinet al 2009

27Notrandomized

Yes Yes Yes No No Yes Yes No Yes No Yes NIH/NIDCRand VA

Fair Fair

Pediatricclinicians canhelp reducerates of earlychildhoodcaries: effectsof a practice-basedintervention

Lawrence et al2008

28Yes Unclear Yes Yes Yes No No Yes No/No Yes No Yes The Institute of

Aboriginal Peoples’Health of theCanadian Institutesof Health Research(Grant # MOP-64215) and theToronto Hospital forSick ChildrenFoundation (Grant #XG 03-067)

Limited:Aboriginalcommunities inrural Canada

Good

A 2-y community-randomizedcontrolled trialof fluoridevarnish toprevent earlychildhoodcaries inAboriginalchildren

Oscarson et al2006

29NR NR Yes Yes Yes No No Yes No Yes No Yes Grants from Count

of Vasterbotten,the PatientRevenue Fundfor DentalProphylaxisand theSwedishDental Society

Fair Fair

Influence ofa low xylitol-dose onmutansstreptococcicolonizationand cariesdevelopment inpreschoolchildren

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TABLE 1 Continued

Author,Year, Title






CareProviderMasked?

PatientMasked?



andContamination


High




FundingSource

ExternalValidity

QualityRating

Seki et al 201130

No No Unclear (dfsindex)

Yes Yes No No Yes Yes Yes Yes Yes The Uemura Fund,Nihon UniversitySchool of Dentistry,a grant to promotemultidisciplinaryresearch projectsfrom the Ministry ofEducation, Science,Sports, Culture andTechnology, Japan

Fair PoorEffect ofxylitol gumon thelevel oforal mutansstreptococciofpreschoolers:block-randomizedtrial

Slade et al 201131

Yes Yes Yes; somedifference influoridationstatus

Yes No No No Yes No/No Yes No Yes Project grant#320858 from theAustralian NationalHealth and MedicalResearch Council

Limited:Aboriginalcommunities inrural Australia

GoodEffect of healthpromotion andfluoridevarnish ondental cariesamongAustralianAboriginalchildren:results froma community-randomizedcontrolled trial

Weinstein et al2001

32Yes Unclear Unclear Yes Unclear Unclear Unclear Yes Yes/Yes Yes No Yes Grant No. R03 DE-

012138 fromNIDCR/NIH

Head Startprogram

Fair

Equivalencebetweenmassive versusstandardfluoridevarnishtreatments inhigh carieschildren aged3-5 y

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TABLE 1 Continued

Author,Year, Title






CareProviderMasked?

PatientMasked?



andContamination


High




FundingSource

ExternalValidity

QualityRating

Weinstein et al2009

33Yes Unclear No;meandmfswere

not balancedYes Yes Unclear Unclear Yes No/No Yes No Yes Grants No.

R01DE14403 andU54DE14254 fromNIDCR, NIH

Head Startprogram

Fair

Randomizedequivalencetrial ofintensive andsemiannualapplications offluoridevarnish in theprimarydentition

Weintraub et al2006

34Yes Yes Yes; stated no

imbalancesapparent

Yes Yes No Yes Yes Yes/No Yes No Yes USPHS ResearchGrants P60 DE13058and U54 DE142501from the NIDCR andthe NCMHD, NIH,and by the UCSFDepartment ofPreventive andRestorative DentalSciences

Limited:“Underserviced”community inUnited States;all nonwhite

Fair

Fluoridevarnishefficacyin preventingearly childhoodcaries

Zhan et al 201235

Yes Unclear Yes Yes Yes Yes Yes Yes No/Yes (23%in 1 group)

Yes No Yes CaliforniaSociety ofPediatric DentistryFoundation, aGraduate ScientificResearch Awardfrom AmericanAcademy ofPediatric Dentistry,and NIH/NIDCRgrant U54DEO19285

Single Center FairEffects ofxylitolwipes oncarcinogenicbacteria andcaries inyoungchildren

dfs, decayed filled surfaces; NCMHD, National Center on Minority Health and Health Disparities; NIDCR, National Institute of Dental and Craniofacial Research; NIH, National Institutes of Health; UCSF, University of California San Francisco; USPHS, UnitedStates Public Health Service; VA, Veterans Affairs; NR, not reported.

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children. The main methodologicalshortcoming in the fair-quality trialwas differential loss to follow-up in thetreatment groups.34 The 2 good-qualitytrials were conducted in rural aborig-inal populations in Canada (no fluori-dation)28 and Australia (,0.6 ppm Ffor .90% of children, baseline dmfsscores of 3.8 and 11.0)31 and useda cluster design. The fair-quality trialenrolled underserved, primarily His-panic and Chinese children in an urbanUnited States setting with adequatefluoridation (1 ppm F) who werecaries-free at baseline.34 In all studies,the fluoride varnish was applied bydental personnel.

All 3 trials found use of fluoride varnishassociated with decreased caries in-cidence after 2 years, although thedifference was not statistically signifi-cant in the Canadian study.28 Percentreductions in dmfs increment were18% and 24% in the 2 good-qualitytrials,28,31 and 59% in the fair-quality

trial.34 Absolute mean reductions inthe number of affected surfaces rangedfrom 1.0 to 2.4. Results were consis-tent with findings from the 2004USPSTF review, which reported a per-cent reduction in incident carieslesions that ranged from 37% to 63%(absolute reduction in the mean num-ber of cavities per child of 0.67 to 1.24per year), based on 6 trials, 2 of whichwere randomized.52–57

Two trials found multiple fluoridevarnish applications within a 2-weekperiod associated with no clear differ-ences versus a standard applicationschedule of every 6 months,32,33 and 1trial found no clear difference betweena once versus twice yearly schedule(Table 2).34

Xylitol

Three trials compared xylitol to noxylitol (Table 3).29,30,35 Water was in-adequately fluoridated in 1 trial30 andwater fluoridation status was not

reported in the other 2. The trialsvaried with respect to dosing and for-mulation of xylitol. A fair-quality ran-domized trial (n = 115) of children 2years of age found xylitol tablets (0.48g) associated with reduced dmfs in-crement after 2 years, but the differ-ence was not statistically significant(mean percent reduction 52%, abso-lute mean reduction in affected surfa-ces 0.42).29 One small (n = 37) fair-quality randomized trial found xylitolwipes used 3 times per day for 1 yearmarkedly more effective than placebowipes in reducing caries among chil-dren aged 6 to 35 months (reduction indmfs increment 91%, P , .05).35 Apoor-quality, nonrandomized trialfound no effect of xylitol chewing gum(1.33 g) 4 times daily on incidence ofcaries in 4-year old children in Ja-pan.30 Xylitol was not an included in-tervention in the 2004 USPSTF review.

Two studies compared xylitol to topicalfluoride (Table 3).23,26 A cluster

FIGURE 2Literature flow diagram. aCochrane databases include the Cochrane Central Register of Controlled Trials and the Cochrane Database of SystematicReviews. bIdentified from reference lists, hand searching, suggested by experts, and so forth. cStudies may have provided data for more than 1 keyquestion. dStudies that provided data and contributed to the body of evidence were considered “included.” eFive studies reported in the full evidencereview18 but not reported in this article evaluated topical fluoride varnishes not commonly used in the United States,36,37 compared different dosingregimens of xylitol,38 or evaluated povidone-iodine39 or chlorhexidine varnish.40

340 CHOU et al

TABLE 2 Summary of Topical Fluoride Preventive Treatments

Author, Year,Quality

Study Design Interventions Country; Setting;Fluoridation Status

Age atEnrollment

SampleSize

F-U, y Mean CariesIncrement

Absolute Reduction inCaries Increment

Reduction in CariesIncrement

Other Dental CariesOutcomes

Lawrence et al200828 Good

Cluster RCT (20clusters)

A: 0.3–0.5 mL 5% sodiumfluoride varnishapplied to full primarydentition every 6 mo

Canada; Rural Aboriginalcommunities; Waterfluoridation status: Nofluoridation

2.5 y 1146 2 dmfs 2.4 (1.8)a 18% (29%)a A versus B

B: No fluoride varnish A: 11.0 (4.3)a Dental caries in aboriginalcohort: 72% (595/832) vs75% (247/328), adjustedOR 0.72 (95% CI 0.42–1.25);NNT 26

B: 13.4 (6.1)a Dental caries in those caries-free at baseline: 44% (157/354) vs 58% (73/126);adjusted OR 0.63 (95% CI0.33–1.1); NNT 7.4

P = .24 (P = .18)a

Slade et al 201131

GoodCluster RCT (30clusters)

A: 0.25 mL of 5% sodiumfluoride varnish tomaxillary anteriorteeth/molars,mandibular molars/incisors every 6 mo,education/advice tocaregiver withtoothbrush/pasteprovided, communityoral health promotionprogram

Australia; RuralAboriginalcommunities; Waterfluoridation status:81% to 92% had,0.6 ppm F

2.8 y 666 2 dmfs 2.3 24%

B: No interventions A: 7.3B: 9.6b

P , .05Weinstein et al

200132 FairRCT with 3treatmentgroups

A: One application of 5%fluoride varnish atbaseline and 6 mo

United States; Head Startprograms; Waterfluoridation status: NR

3–5 y 111 1 Clinical dmfs A:4.6

Not calculated Not calculated

B: Three applications of5% fluoride varnishwithin 2 wk of baseline

B: 3.2

C: Three applications of5% fluoride varnishwithin 2 wk of baselineand 6 mo

C: 4.7

P = .65Radiographicmean dmfs

A: 0.9B: 0.5C: 0.1P = .28

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TABLE 2 Continued



Age atEnrollment

SampleSize


Absolute Reduction inCaries Increment

Reduction in CariesIncrement


Weinstein et al200933 Fair

RCT with 2treatmentgroups

A:One5%fluoridevarnishtreatment and 2placebo treatmentsevery 6 mo

United States 55–56 mo 515 3 dmfs 2.4 24% Adjusted rate ratio of newtooth decay in primarysurfaces 1.13 (95% CI0.94–1.37)

B: Oneset of 3, 5%fluoridevarnish treatmentsover 2 wk once peryear and 3 placebotreatments over 2 wk,6 mo later

Recruitment setting:Head Start programs

A: 7.4

Waterfluoridationstatus:NR (Yakima votersapproved fluoridationin 1999)

B: 9.8

P = .001Weintraub et al200634,c Fair

RCT A: 0.1 mL of 5% sodiumfluoride varnish perarch applied twice peryear with 4 intendedapplications

United States; Familydental center andpublic health centerserving primarily low-income, underservedHispanic and Chinesepopulations

1.8 y 280 2 d2+fsd 1.0 59% (A + B vs C) A vs B vs C

B: 0.1 mL of 5% sodiumfluoride varnish perarch applied once peryear with 2 intendedapplications

Waterfluoridationstatus:Approximately 1 ppm

A: 0.7 Caries lesions at 12 mo: 13%(11/83) vs 15% (13/86) vs29% (27/92); RR 0.45 (95%CI 0.24–0.85); NNT 7 for A vsC and 0.52 (95% CI 0.28–0.93); NNT 8 for B vs C

C: No fluoride varnish B: 0.7 Caries lesions at 24 mo: 4.3%(3/70) vs 14% (10/69) vs24% (15/63); RR 0.18 (95%CI 0.06–0.59); NNT 6 for A vsC and 0.61 (95% CI 0.30–1.26); NNT 11 for B versus C

C: 1.7P, .01 for A or

B vs C

ANOVA, analysis of variance; CI, confidence interval; d2+fs, number of decayed or filled surfaces; F-U, follow-up; NNT, number needed to treat; NR, not reported; RCT, randomized controlled trial; RR, relative risk.a Children caries-free at baseline.b Adjusted.c In the fluoride varnish treatment group, some children received a placebo varnish instead of fluoride varnish due to protocol errors.d Participants were caries-free at baseline.

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TABLE 3 Summary of Xylitol Preventive Treatments



Age atEnrollment

SampleSize


Absolute Reductionin Caries Increment

Reduction inCaries Increment


Alamoudi et al201223 Poor

RCT A: Xylitol chewabletablets (1.2 g, 84%xylitol) chewed for5 min 3 times daily

Saudi Arabia;Recruitmentsetting: Well-infantclinics and dentalclinics; Waterfluoridation status:Not reported

2–5 y 34 1.5 dmft 3.6 82% A vs B

B: Fluoride varnish,every 6 mothroughout study

A: 0.8 dmft at baseline: 8.4 vs 10.3(P = .19) dmft at 18 mo:9.2 vs 14.7 (P = .001)

B: 4.4P = not reported

Kovari et al200326, a Fair

Cluster RCT (11clusters)

A: 65% Xylitol gum 3times per day,chewed for 3–5 min,for total of 2.5 g/d

Finland; Recruitmentsetting: day carecenters; Waterfluoridation status:Not reported

3–6 y 786 3–6 Not reported Not reported Not reported A vs B

B: Tooth brushing with0.05% NaFtoothpaste afterlunch

Caries at 7 y old: 31% (98/316) vs 35% (149/427),RR 0.88 (95% CI 0.72–1.10)

Caries at 9 y old: 43% (133/310) vs 51% (221/434),RR 0.84 (95% CI 0.72–0.99)

dmft: 1.1 vs 1.0 at 7 y, 1.2 vs1.6 at 9 y

Oscarson et al200629 Fair

RCT A: One 0.48-g xylitoltablet at bedtimeafter brushing for6 mo; then 1 tablettwice daily to age 3 yand 6 mo

Sweden; Recruitmentsetting: Publicdental clinic; Waterfluoridation status:Not reported

25 mo 115 2 dmfs 0.42 52% A vs B

B: No tablets A: 0.38 Dental caries: 18% (10/55)vs 25% (16/63), OR 0.65(95% CI 0.27–1.59)

B: 0.80P . .05

Seki et al 201130

PoorCluster, non–randomizedcontrolled clinicaltrial (3 clusters)

A: Xylitol chewing gum(100% xylitol, 1.33 g);1 pellet chewed 5min 4 times daily

Japan; Recruitmentsetting: Preschool;Water fluoridationstatus: Not reported(states fluoridation“limited” in Japan)

66%–72%4 y old

161 1 dfs 0.1 3% A vs B

B: No intervention A: 3.3 Development of caries frombaseline–6 mo: 1.7 vs 1.6(P . .05)

B: 3.4 Development of caries from6 mo–1 y: 1.6 vs 1.8(P . .05)

P . .05

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randomized trial found no differ-ence between 65% xylitol gum 3 timesper day versus tooth brushing withfluoride, but was conducted in a su-pervised day care setting, andenrolled children up to 6 years of age,potentially limiting its applicability toyounger children.26 A poor-quality trialfound xylitol chewable tablets (1.2 g 3times daily) more effective than fluo-ride varnish once every 6 months.23

Harms of Preventive Interventions

A systematic review included in the2004 USPSTF review (searches con-ducted through September 1997) hassubsequently been updated (searchesconducted through June 2006).21 Theupdate included 5 new observationalstudies on the association betweenearly childhood intake of fluoridesupplements and risk of fluorosis.58–62

Determinations of early childhoodexposures were all based on retro-spective parental recall, with fluorosisassessed at 8 to 14 years of age.Results of the new studies were con-sistent with the original systematicreview, with intake of fluoride sup-plements before 7 years of age (pri-marily before 3 years of age)associated with increased risk offluorosis. Risk estimates ranged froman odds ratio (OR) of 10.8 (95% confi-dence interval 1.9–62.0) with intakeduring the first 2 years of life,61 toa slight increase in risk (OR 1.1–1.7,depending on comparison).58 Onestudy reported a dose-dependent as-sociation, with an OR of 1.8 (95%confidence interval 1.4–2.4) for eachyear of supplementation.62 In theprior systematic review, the ORs fordental fluorosis associated withregular early childhood use rangedfrom 1.3 to 10.7 in 10 studies thatrelied on retrospective recall andrelative risks ranged from 4.2 to 15.6in 4 studies that recorded supple-ment use at the time of exposure. Weidentified no studies published sinceTA

BLE3

Continued

Author,Year,

Quality

StudyDesign

Interventions

Country;Setting;

FluoridationStatus

Ageat

Enrollm

ent

Sample

Size

F-U,y

MeanCaries

Increm

ent

AbsoluteReduction

inCaries

Increm

ent

Reductionin

Caries

Increm

ent

OtherDentalCaries

Outcom

es

Zhan

etal

2012

35Fair

RCT

A:Xylitolwipes,2

atatim

e,3tim

esper

day(estimated

daily

dosage

4.2g)

every3mo

UnitedStates;

Recruitm

ent

setting:University

pediatricclinic;

Water

fluoridation

status:Notreported

6–35

mo

371

dmfsb

0.48

91%

Avs

B

B:Placebowipes

A:0.05

Newcaries

lesionsat1yb:

5%vs

40%(P

=.03);

NNT3

B:0.53

ITTanalysisofnewcaries

lesionsat1y:5%

vs32%;

RR0.14

(95%

CI0.02–

1.07);NN

T4

P=.01

CI,confidenceinterval;dfs,decayed

andfilledsurfaces;dmft,decayed,missing,and

filledteeth;F-U,follow-up;NN

T=numberneeded

totreat;OR,oddsratio;RCT,randomized

controlledtrial;RR,relativerisk.

aBaselinecaries

status

notdefined.

bNumbers

basedon

perprotocolanalysis.

344 CHOU et al

the updated systematic review on theassociation between early childhoodintake of dietary fluoride supple-ments and risk of enamel fluorosis.

No study reported the risk of fluo-rosis associated with use of fluoridevarnish. However, the degree ofsystemic exposure after applicationof fluoride varnish is believed to below.

Two trials reported diarrhea in 11%of children allocated to xylitol chewinggum30 or syrup.38 Other trials of xyli-tol23,26,29 did not report rates of di-arrhea.

DISCUSSION

As in the 2004 USPSTF review,2 we foundno direct evidence on the effects ofscreening for dental caries by primarycare clinicians in children ,5 yearsof age versus no screening on cariesincidence and related outcomes. Evi-dence reviewed for this update issummarized in Table 4.

New evidence was consistent withfindings from the 2004USPSTFreview inshowing that fluoride varnish in chil-dren ,5 years of age is effective atreducing caries incidence.28,31,34 Be-cause trials were primarily conductedin higher-risk children (based on com-munity water fluoride levels or socio-economic status), the applicability ofthese findings to children not at in-creased risk may be limited, particu-larly for studies conducted in countriesand settings in which sources of fluo-ride and health behaviors differ mark-edly from the United States. In all trials,the varnish was applied by dental per-sonnel, although fluoride varnish isconsidered easy to apply with minimaltraining.63,64

We identified no new trials on the ef-fectiveness of dietary fluoride supple-mentation in children,5 years of age.Although the 2004 USPSTF review founddietary fluoride supplementation to be

effective at reducing caries incidencein children ,5 years of age primarilyin settings with water fluoridationlevels ,0.6 ppm F, conclusions weremostly based on nonrandomized tri-als.2 Newer observational studies wereconsistent with the 2004 USPSTF re-view in finding an association betweenearly childhood intake of dietaryfluoride supplementation and risk ofenamel fluorosis.21 Risk of enamelfluorosis appears to be affected bytotal intake of fluoride (from supple-ments, drinking water, other dietarysources, and dentifrices), as well asage at intake, with intake before 2 to 3years of age appearing to conferhighest risk.65 Although the preva-lence of enamel fluorosis has in-creased in the United States, severefluorosis is uncommon, with a preva-lence of ,1%.66–68

Trials of xylitol in children,5 years ofage found no clear effects on cariesincidence, although studies differedin the doses and formulations eval-uated.29,30,35 The most promising re-sults were from a small trial of xylitolwipes that reported a marked de-crease in caries incidence, but requireconfirmation.35

Evidence remains limited on the ac-curacy of primary care clinicians inidentifying caries lesions in children,5 years of age or predicting cariesincidence. One study not included in theprevious USPSTF review found thatprimary care pediatricians missed37% of children in need of a dentalreferral and 24% of children witha cavity, compared with a pediatricdentist examination, although speci-ficity was high.41 No study evaluated thediagnostic accuracy of caries riskassessment instruments administeredby primary care clinicians, despite theavailability of instruments designed foruse in primary care settings.43 Somestudies have assessed caries risk as-sessment instruments in children

younger than 5 years of age, but theinstruments were not administered byprimary care providers or in primarycare settings. These instruments oftenincorporate findings from an oral ex-amination by dental personnel, andinclude tests not commonly obtained inprimary care (such as mutans strep-tococci levels, saliva secretion level, orsaliva buffer capacity),69,70 likely limit-ing their applicability to primary caresettings.71,72

No trial specifically evaluated theeffectiveness of parental or caregivereducation on caries outcomes, al-though limited evidence from 2 trialssuggests that multifactorial inter-ventions that included an educationalcomponent could be effective.12,24,25,27,

Although some evidence indicatesthat health care providers’ recom-mendation for dental care increasesthe likelihood of subsequent dentalvisits in young children,12 no trial di-rectly evaluated the effectivenessof primary care referral to a dentiston caries outcomes, although 1 ret-rospective cohort study suggeststhat earlier dental care (before 18months of age) is associated withfewer subsequent dental proceduresin children with dental disease atbaseline.45

Our review has some limitations. Weexcluded non–English language arti-cles, which could result in languagebias, although we did not identify non–English language studies otherwisemeeting inclusion criteria. We did notsearch for studies published only asabstracts and could not formally as-sess for publication biaswith graphicalor statistical methods because of smallnumbers of studies for each keyquestion and differences in study de-sign, populations, and outcomes as-sessed. We found few or no randomizedtrials for a number of key questions.Therefore, we included nonrandomizedtrials, as well as observational

REVIEW ARTICLE


TABLE 4 Summary of Evidence

Main Findings From 2005 USPSTFReview

Number and Type of Studies Identifiedfor Update Overall Qualitya

Limitations Consistency Applicability Summary of Findings

Key Question 1. How effective is oral screening (including risk assessment) by the primary care clinician in preventing dental caries in children ,5 y of age?No evidence No studies No studies No studies No studies No randomized trial or observational

study compared clinical outcomesbetween children ,5 y of agescreened and not screened byprimary care clinicians.

Key Question 2a. How accurate is screening by the primary care clinician in identifying children ,5 y of age who have cavitated or noncavitated caries lesions?One study found pediatrician

examination after 4 h of oralhealth education associated witha sensitivity of 1.0 and specificityof 0.87 for identifying nursingcaries in children 18 to 36 mo ofage.

One cohort study Evidence limited to twostudies, one good-quality

N/A Study conducted in a primary caresetting

One study found primary carepediatricianexaminationafter 2hoforal health education associatedwith a sensitivity of 0.76 foridentifying a child with 1 or morecavities and 0.63 for identifyingchildren ,36 mo of age in need ofa dental referral, compared witha pediatric dentist evaluation.

Overall quality: Fair

Key Question 2b. How accurate is screening by the primary care clinician in identifying children ,5 y of age who are at increased risk for future dental caries?No evidence No studies No studies No studies No studies No study evaluated the accuracy of

general assessment or use of riskassessment tools by primary careclinicians to identify children atincreased risk for future dentalcaries.

Key Question 3. What are the harms of oral health screening by the primary care clinician?No evidence No studies No studies No studies No studies No randomized trial or observational

study compared harms betweenchildren ,5 y of age screened andnot screened by primary careclinicians.

Key Question 4. How effective is parental or caregiver/guardian oral health education by the primary care clinician in preventing dental caries in children ,5 y of age?No evidence 1 randomized trial, 1 nonrandomized

trialNonrandomized design, high attrition,failure to adjust for confounders.

Moderateinconsistency

Education evaluated as part ofa multifactorial intervention

No trial specifically evaluated aneducational or counselingintervention to prevent dentalcaries. Two studies foundmultifactorial interventions thatincluded an educational componentassociated with decreasedincidence or prevalence of cavitiesin underserved children ,5 y ofage.

Overall quality: Poor

346CHOU

etal

TABLE 4 Continued

Main Findings From 2005 USPSTFReview

Number and Type of Studies Identifiedfor Update Overall Qualitya

Limitations Consistency Applicability Summary of Findings

Key Question 5. How effective is referral by a primary care clinician to a dentist in preventing dental caries in children ,5 y of age?No evidence 1 cohort study Study not designed to determine

whether a primary care referralwas the source of the initialpreventive visit

N/A Medicaid population, higher-riskchildren

No study directly evaluated the effectsof referral by a primary careclinician to a dentist on cariesincidence. One study found a firstdental preventive visit after 18moofage in children with existing dentaldisease associated with increasedrisk of subsequent dentalprocedures compared with a firstvisit before18moofage, butwasnotdesigned to determine referralsource.

Overall quality: Poor

Key Question 6. How effective is preventive treatment with dietary fluoride supplementation in preventing dental caries in children ,5 y of age?Six trials of dietary fluoride

supplements. One randomizedtrial and 4 other trials found oralfluoride supplementation insettings with water fluoridationlevels , 0.6 ppm F associatedwith decreased caries incidenceversus no fluoridation (ranges of48%–72% for primary teeth and51%–81% for primary toothsurface).

No studies Limitations in previously reviewedstudies include use ofnonrandomized design, notcontrolling for confounders,inadequate blinding and high orunreported attrition

N/A No studies We identified no new trials on theeffects of dietary fluoridesupplementation in children,5 y ofage on dental caries incidence.


Key Question 6. How effective is preventive treatment with topical fluoride application (fluoride varnish) in preventing dental caries in children ,5 y of age?Three randomized trials found

fluoride varnish more effectivethan no fluoride varnish inreducing caries incidence(percent reduction 37%–63%,with an absolute reduction in themean number of cavities perchild of 0.67–1.24 per year.)

3 randomized trialsb; High loss to follow-up, failure todescribe adequate blinding, andfailure to describe adequateallocation concealment

Consistent Rural settings with inadequatefluoridation or low socioeconomicstatus settings

Three randomized trials publishedsince the previous review foundfluoride varnishmore effective thanno fluoride varnish in reducingcaries incidence (percent reductionin caries increment 18%–59%).Other trials evaluated methods oftopical fluoride application notused in the United States orcompared different doses orfrequencies of topical fluoride.


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347

studies (for harms), which are moresusceptible to bias and confoundingthan are well-conducted randomizedtrials.

Research is needed to identify effectiveoral health educational and counselinginterventions for parents and care-givers of young children. Research isalso needed to validate the accuracyand utility of caries risk assessmentinstruments for use in primary caresettings, and to determine how referralby primary care physicians of youngchildren for dental care affects cariesoutcomes.

CONCLUSIONS

Dental caries is common in youngchildren, many of whom do not receivedental care. Dietary fluoride sup-plementation and fluoride varnishare primary care–feasible interven-tions that appear to be effective atpreventing caries outcomes in higher-risk children. Dietary fluoride sup-plementation in early childhood isassociated with risk of enamel fluo-rosis, which is usually mild. More re-search is needed to understand theaccuracy of oral health examinationand caries risk assessment by pri-mary care providers, effectiveness ofprimary care referral for dental care,and effective parental and caregivereducational and counseling inter-ventions.

ACKNOWLEDGMENTSTheauthors thank the responsiblemed-ical officer at the Agency of HealthcareResearch and Quality, Aileen Buckler,MD, MPH; and US Preventive ServicesTask Force members Linda Baumann,PhD, RN, Adelita Cantu, PhD, RN, DavidGrossman, MD, MPH, Glenn Flores,MD, and Virginia Moyer, MD, MPH. Wealso thank Andrew Hamilton, MLS, MS,for assistance with literature searchesandAmandaBrunton, BS, forassistancewith preparing this article.TA

BLE4

Continued

MainFindings

From

2005

USPSTF

Review

NumberandType

ofStudiesIdentified

forUpdateOverallQualitya

Limitations

Consistency

Applicability

SummaryofFindings

KeyQuestion6.Howeffectiveispreventivetreatm

entw

ithxylitolinpreventingdentalcaries

inchildren,5yofage?

Nostudies(notincluded

intheprior

review

)4random

ized

trials;1nonrandomized

bVariabilityinxylitolform

ulationand

dosing

Some

inconsistency

Childrenfrom

settings

inwhich

water

was

notfluoridatedor

fluoridation

limited

Threetrialsreported

nocleareffectsof

xylitolversus

noxylitolon

caries

incidenceinchildrenyoungerthan

5y,with

themostpromisingresults

from

asm

all(n=37)trialofxylitol

wipes.One

trialfound

nodifference

betweenxylitolandtoothbrushing.

Overallquality:Fair

KeyQuestion7.Whatare

theharm

sofspecificoralhealthinterventions

forpreventionofdentalcaries

inchildren,5yofage(parentalorcaregiver/guardian

oralhealtheducation,referraltoadentist,andpreventive

treatm

ents)?

Onesystem

aticreview

of14

observationalstudies

found

dietaryfluoride

supplementationinearly

childhood

associated

with

increasedrisk

offluorosis;OR

sranged

from

1.3–15.6and

prevalence

ranged

from

10%–

67%.

5observationalstudies

inan

updated

system

aticreview

Useofretrospectiveparentalrecallto

determ

ineexposures

Consistent

Dosesoffluoride

generallyhigherthan

currently

recommended

Weidentified

nostudiespublished

sincetheupdatedsystem

aticreview

ontheassociationbetweenearly

childhood

ingestionofdietary

fluoride

supplementsandrisk

ofenam

elfluorosis.Fivenewstudiesin

anupdatedsystem

icreview

were

consistentwith

previouslyreported

findings

inshow

ingan

association

betweenearlychildhood

ingestion

ofsystem

icfluoride

andenam

elfluorosis.Otherthan

diarrhea

reported

in2trialsofxylitol,harms

werepoorlyreported

inothertrials

ofcariespreventioninterventions

inchildren,5yofage.

Overallquality:Fair

aOverallqualityisbasedon

newevidence

identified

forthisupdateplus

previouslyreview

edevidence.

bFive

studiesreported

inthefullevidence

review

18butnotreportedinthisarticleevaluatedtopicalfluoride

varnishesnotcommonlyused

intheUnitedStates,36

,37compareddifferent

dosing

regimensofxylitol,38

orevaluatedpovidone-iodine

39or

chlorhexidinevarnish.40N/A,notapplicable.

348 CHOU et al

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Preventing Dental Caries in Children