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Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Ages 5 to 17 Years: A Systematic Review for the U.S. Preventive Services Task Force
Evidence Synthesis, No. 232
Investigators: Roger Chou, MD, Christina Bougatsos, MPH, Jessica Griffin, MS, Shelley S. Selph, MD, MPH, Azrah Ahmed, BA, Rongwei Fu, PhD, Chad Nix, MSc, CIC, and Eli Schwarz, DDS, MPH, PhD.
Structured Abstract
Background:
Dental caries is common in children and adolescents 5 to 17 years of age. The U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians prescribe oral fluoride supplementation in areas with fluoride deficient water and apply fluoride varnish to the primary teeth in children younger than 5 years, but has not addressed oral health screening and prevention in children and adolescents 5 to 17 years of age.
Purpose:
To systematically update the evidence on primary care screening and prevention of dental caries in children and adolescents 5 to 17 years of age.
Data Sources:
We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, and MEDLINE to October 3, 2022, and manually reviewed reference lists; with surveillance through July 21, 2023.
Study Selection:
Studies on diagnostic accuracy of primary care screening instruments and oral examination; randomized controlled trials (RCTs) and non-randomized trials of screening and preventive interventions; cohort studies on risk of fluorosis with fluoride preventive interventions; and cohort studies of oral health screening in primary care.
Data Extraction:
One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the USPSTF.
Data Synthesis (Results):
Twenty-three studies (reported in 27 publications; 19 RCTs, 3 non-randomized trials, and 1 observational study; total 15,026 participants) and three systematic reviews (with 54 trials; total 20,684 participants) were included in this update. No study compared screening versus no screening. For identification of untreated caries in children 5 to 12 years of age, one study (n=219) found visual screening by a registered nurse associated with sensitivity of 0.92 (95% confidence interval [CI] 0.84 to 0.97) and specificity of 0.993 (95% CI 0.96 to 0.998), and a 17-item questionnaire (n=305) associated with sensitivity of 0.69 (95% CI 0.60 to 0.77) and specificity of 0.88 (95% CI 0.83 to 0.93). No study trial evaluated the effectiveness of primary care oral health behavioral counseling versus no counseling or primary care referral to a dental health provider versus no referral. Fluoride supplements compared with placebo or no intervention were associated with decreased change from baseline to followup in the number of decayed, missing, or filled teeth (DMFT) or decayed, or filled teeth (DFT) increment at 1.5 to 3 years (six trials, N=1,395; mean difference -0.73, 95% CI -1.30 to -0.19) in low socioeconomic, nonfluoridated water, or high caries burden settings; though the only trial in which fluoride supplements were administered at home (rather than in supervised school settings) reported low adherence with no benefit (n=438, mean difference 0.13, 95% CI -0.38 to 0.64). Good-quality systematic reviews found fluoride gels associated with decreased caries in permanent teeth at outcomes closest to 3 years (DMFT/DFT prevented fraction 0.18, 95% CI, 0.09 to 0.27, based on four placebo-controlled trials [N=1,525]), fluoride varnish associated with decreased caries burden at 1 to 4.5 years (decayed, missing, or filled surfaces [DMFS] or decayed or filled surfaces [DFS] prevented fraction 0.43, 95% CI 0.30 to 0.57, based on 14 trials [N=3,419] and DMFT or DFT prevented fraction 0.44, 95% CI 0.11 to 0.76, based on five trials [N=3,902], and resin-based sealants in children 5 to 10 years of age associated with decreased risk of carious first molars at 24 months (seven trials, N=1,322, odds ratio [OR] 0.12, 95% CI 0.08 to 0.19), 36 months (seven trials, N=1,410, OR 0.17, 95% CI 0.11 to 0.27) and 48 to 54 months (four trials, N=440, OR 0.21, 95% CI 0.16 to 0.28). One trial found silver diamine fluoride associated with fewer new active caries surfaces in deciduous dentition (mean 0.3 vs. 1.4, p<0.001) and first permanent molars (mean 0.4 vs. 1.1, p<0.001) and decreased likelihood of ≥1 new decayed or filled teeth (relative risk [RR] 0.52, 95% CI 0.40 to 0.70). One fair-quality trial (n=496) found no difference between xylitol versus no xylitol in DMFS increment and another fair-quality trial (n=432) found xylitol associated with decreased caries increment versus no xylitol but no difference versus placebo. Reporting of harms was very limited, although serious harms were not reported.
Limitations:
Oral health preventive interventions were administered by dental professionals or in supervised school settings, with uncertain applicability to primary care administration; only English-language articles were included; sparse or no evidence on screening, referral, and some preventive interventions; most studies had methodological limitations; and few studies published after the year 2000.
Conclusions:
Supervised administration of fluoride supplements in schools and administration of fluoride gels, varnish, and sealants in dental or school settings improved caries outcomes. Research is needed on the effectiveness of these oral health preventive interventions when administered at home or in primary care settings, and to determine the accuracy of primary care screening, and the benefits and harms of screening, as well as the effectiveness of primary care counseling, dental referral, and other oral health preventive interventions.
Contents
Suggested citation:
Chou R, Bougatsos C, Griffin J, Selph SS, Ahmed A, Fu R, Nix C, Schwarz E. Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Ages 5 to 17 Years: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 232. AHRQ Publication No. 23-05304-EF-1. Rockville, MD: Agency for Healthcare, Research and Quality; 2023.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00006, Task Order No. 75Q80121F32009). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
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