Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.
Frequency of Service
No studies specifically addressed the dosage and timing of oral fluoride supplementation in children with inadequate water fluoridation. The American Dental Association (ADA) recommendations on the dosage of and age at which to start dietary fluoride supplementation take into account the amount of fluoride in the child's water source. These dosing recommendations are also referenced by the American Academy of Pediatrics (AAP).
Risk Factor Information
All children are at potential risk for dental caries; those whose primary water supply is deficient in fluoride (defined as containing <0.6 ppm F) are at particular risk. While there are no validated multivariate screening tools to determine which children are at higher risk for dental caries, there are a number of individual factors that elevate risk. Higher prevalence and severity of dental caries are found among minority and economically disadvantaged children. Other risk factors for caries in children include frequent sugar exposure, inappropriate bottle feeding, developmental defects of the tooth enamel, dry mouth, and a history of previous caries. Maternal and family factors can also increase children's risk. These factors include poor oral hygiene, low socioeconomic status, recent maternal caries, sibling caries, and frequent snacking. Additional factors associated with dental caries in young children include lack of access to dental care; inadequate preventive measures, such as failure to use fluoride-containing toothpastes; and lack of parental knowledge about oral health.
Patient Population Under Consideration
This recommendation applies to children age 5 years and younger.
The USPSTF limited its consideration of caries screening and prevention by primary care clinicians to infants and preschool-aged children. The rationale for this decision was that, at the present time, nondental primary care clinicians are more likely than dentists to have contact with children ages 5 years and younger in the United States 6, 7; this situation changes as children reach school age and beyond. In addition, as children grow older, dental professionals use sealants rather than fluoride varnish. As such, the USPSTF limited its review of the evidence of preventive interventions for dental caries to this age group. This recommendation should not be construed to imply that preventive interventions for dental caries should cease after 5 years of age.
Assessment of Risk
All children are at potential risk for dental caries; those whose primary water supply is deficient in fluoride (defined as containing <0.6 ppm F) are at particular risk. While there are no validated multivariate screening tools to determine which children are at higher risk for dental caries, there are a number of individual factors that elevate risk. Higher prevalence and severity of dental caries are found among minority and economically disadvantaged children. Other risk factors for caries in children include frequent sugar exposure, inappropriate bottle feeding, developmental defects of the tooth enamel, dry mouth, and a history of previous caries. Maternal and family factors can also increase children's risk. These factors include poor oral hygiene, low socioeconomic status, recent maternal caries, sibling caries, and frequent snacking. Additional factors associated with dental caries in young children include lack of access to dental care; inadequate preventive measures, such as failure to use fluoride-containing toothpastes; and lack of parental knowledge about oral health 8, 9.
Some organizations have advocated restricting fluoride varnish use to children at “increased risk.” Although several caries risk assessment tools exist, none have been validated in the primary care setting, nor do existing studies demonstrate that these tools, when used by primary care clinicians, can accurately and consistently differentiate between children who will develop dental caries and those who will not (8, 9). A risk-based approach to fluoride varnish application will miss opportunities to provide an effective dental caries preventive intervention to children who could benefit from it, particularly because currently, in the United States, infants and preschool-aged children are more likely to have regular visits with nondental primary care clinicians than dental care providers 6, 7.
Interventions to Prevent Dental Caries
As noted previously, oral fluoride supplementation prevents dental caries in patients with inadequate water fluoridation.
All children with erupted teeth can potentially benefit from the periodic application of fluoride varnish, regardless of the levels of fluoride in their water. Though the evidence to support varnish is drawn from higher-risk populations, the provision of varnish to all children is reasonable since the prevalence of risk factors is high in the U.S. population, the number needed to treat is low, and the harms of the intervention are small to none.
The USPSTF did not review the evidence on the effectiveness of tooth brushing, but regular tooth brushing with fluoride toothpaste by children is very important in preventing dental caries 10.
Timing and Dosage of Preventive Interventions
No studies specifically addressed the dosage and timing of oral fluoride supplementation in children with inadequate water fluoridation. The American Dental Association (ADA) recommendations on the dosage of and age at which to start dietary fluoride supplementation take into account the amount of fluoride in the child's water source 11. These dosing recommendations are also referenced by the American Academy of Pediatrics (AAP) 12.
No study directly assessed the appropriate ages at which to start and stop the application of fluoride varnish. Available trials of fluoride varnish enrolled children ages 3 to 5 years; however, given the mechanism of action of this intervention, benefits are very likely to accrue starting at the time of primary tooth eruption. Limited evidence found no clear effect on caries increment between performing a single fluoride varnish once every 6 months versus once a year 13 or between a single application every 6 months versus multiple applications once a year or every 6 months 14, 15.
Suggestions for Practice Regarding I Statement
In deciding whether to routinely perform screening examinations for dental caries in children from birth to age 5 years, clinicians should consider the following.
Potential Preventable Burden
Dental caries is the most common chronic disease in children in the United States. It is four times more common than childhood asthma and seven times more common than hay fever. According to the NHANES, the prevalence of dental caries has risen from 24% to 28% between 1988–1994 and 1999–2004 2. Approximately 20% of surveyed children with caries had not received treatment. Symptomatic dental caries in children are associated with pain, loss of teeth, impaired growth, and decreased weight gain and can affect appearance, self-esteem, speech, and school performance. Dental-related concerns lead to the loss of more than 54 million school hours each year 16.
No studies examined the harms of performing primary care screening examinations for dental caries in children from birth to age 5 years 8, 9. However, given the noninvasive nature of an oral examination, these harms are expected to be minimal.
In one study, only about half of pediatricians reported examining the teeth of half of their patients ages 0 to 3 years 17.
Other Approaches to Prevention
In April 2013, the Community Preventive Services Task Force recommended fluoridation of community water sources based on strong evidence of effectiveness in reducing dental caries 18. It also recommends school-based dental sealant delivery programs to prevent caries.
Xylitol may have promise as an additional method to reduce the risk for dental caries. Xylitol is classified by the U.S. Food and Drug Administration as a dietary supplement and is found in over-the-counter consumer products such as wipes or gum. A single small, fair-quality trial of xylitol wipes use in children ages 6 to 35 months found a 91% relative reduction in decayed, missing, or filled surface increment 19. However, four other studies showed no clear effect of xylitol on caries risk in children younger than age 5 years[[20–23]]. As such, there is currently not enough evidence to formally recommend its routine use in caries prevention.
Many primary care providers already prescribe oral fluoride supplementation to patients with low levels of fluoride in their water; however, application of fluoride varnish is not currently commonly performed in many primary care offices (estimated at about 4% of practices in 2009)17. The techniques for application are simple and easy to learn, and fluoride varnish does not require specialized equipment or personnel and can be applied quickly. However, providers and other qualified staff may require some training before offering this procedure24, 25. Dentists and physicians can apply varnish in all states. In some states, physician assistants, nurse practitioners, nurses, and medical assistants can also do so.
Efforts are underway to address concerns surrounding resources, infrastructure, training, and payment mechanisms for the provision of fluoride varnish in the nondental primary care setting. For example, the AAP Section on Oral Health has partnered with the Health Resources and Services Administration's Maternal and Child Health Bureau and the ADA Foundation to educate and advocate for primary pediatric care professionals to apply fluoride varnish. They have created a Web site with a number of helpful tools and resources to assist nondental primary care providers, including how to acquire the materials required to provide varnish, as well as state-by-state information on billing codes and any training requirements (available at www2.aap.org/oralhealth/PracticeTools.html). The National Interprofessional Initiative on Oral Health, a consortium of funders and health professionals, focuses on educating and training primary care clinicians on oral health prevention (additional information available at http://www.niioh.org).
State Medicaid reimbursement for fluoride varnish application, when offered, ranges from $9 to $53 per application when applied by licensed providers who have had appropriate training, including physicians, physician assistants, nurse practitioners, registered nurses, and licensed practical nurses (varying by state) 26.
Research Needs and Gaps
Studies are needed to assess and validate multivariate risk assessment tools that can accurately identify high-risk populations most likely to benefit from caries preventive interventions, such as fluoride varnish.
Further research would also be helpful to confirm the benefits of fluoride varnish among lower-risk and younger children.
Racial and ethnic minority children, as well as children living in low socioeconomic conditions, are at significantly increased risk for caries compared with white children and children who live in adequate to high socioeconomic conditions. Future studies on risk assessment and preventive interventions should enroll sufficient numbers of racial and ethnic minority children to understand the benefits and harms of interventions in these specific populations.
More research is also needed to estimate the effectiveness of interventions by clinicians to educate parents and caregivers about optimum health practices for oral hygiene at home.
Dental caries is the most common chronic disease in children in the United States 1. According to the 1999–2004 National Health and Nutrition Examination Survey (NHANES), approximately 42% of children ages 2 to 11 years have dental caries in their primary teeth. After decreasing from the early 1970s to the mid-1990s, the prevalence of dental caries in children has been increasing, particularly in young children ages 2 to 5 years2.
Recognition of Risk Status
Risk assessment tools generally evaluate risk based on factors such as demographic risk, personal and family oral health history, dietary habits, fluoride exposure, and oral hygiene practices. Information from a clinical evaluation has also been proposed, as well as qualitative or quantitative measure of oral bacterial load. The USPSTF found no studies that evaluated the accuracy of risk assessment instruments for future dental caries in the primary care setting.
Benefits of Preventive Interventions and Early Detection
The USPSTF found adequate evidence that oral fluoride supplementation, also known as dietary fluoride supplementation, in children who have low levels of fluoride in their water and application of fluoride varnish to the primary teeth of all children can each provide moderate benefit in preventing dental caries.
The USPSTF found insufficient evidence on the benefits of provider education of parents regarding oral hygiene practices to prevent dental caries in their children.
The USPSTF found no studies addressing the direct effect of routine oral screening examinations performed by primary care clinicians on improved clinical outcomes in children younger than age 5 years.
Harms of Preventive Interventions and Early Detection
The USPSTF found adequate evidence of a link between early childhood exposure to systemic fluoride and enamel fluorosis, a visible change in the appearance of the enamel due to altered mineralization. Fluorosis can range from mild (small white spots or streaks) to severe (discoloration, pitting, or rough enamel), depending on the overall systemic fluoride exposure level over time.
No studies specifically reported on the risk for fluorosis with fluoride varnish; however, compared with other topical fluoride interventions, systematic exposure to fluoride is low after varnish application3, 4. It is important to consider a child's overall systemic exposure to fluoride from multiple sources (e.g., water fluoridation, toothpaste, supplements, and/or varnish), but in the United States, enamel fluorosis presents as mild cosmetic changes in >99% of cases5.
The USPSTF concludes that there is limited evidence about the harms associated with fluoride varnish or other preventive interventions for dental caries, but that these risks are likely small.
The USPSTF found no studies addressing the magnitude of harms of screening children from birth to age 5 years for dental caries or future risk for dental caries in the primary care setting.
The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with oral fluoride supplementation at recommended doses in children older than age 6 months who reside in communities with inadequate water fluoride.
The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with fluoride varnish application in all children starting at the age of eruption of primary teeth to age 5 years.
The USPSTF concludes that the evidence on performing routine oral screening examinations for dental caries in children from birth to age 5 years is insufficient, and the balance of benefits and harms of screening cannot be determined.
Recommendations of Others The AAP has issued two policy statements related to dental care in children. The first, issued in 2003 and reaffirmed in 2009, encourages providers to incorporate oral health–related services into their practices. Specifically, the AAP recommends an oral health assessment for all children by age 6 months and a first dental visit by age 1 year38. The second statement supports oral fluoride supplementation and application of fluoride varnish in children “at risk” for dental caries39. The ADA recommends that children be seen by a dentist within 6 months of eruption of the first tooth and no later than age 12 months. It also recommends the application of fluoride varnish every 6 months in preschool-aged children who are at “moderate” risk for dental caries and every 3 to 6 months in children who are at “high” risk 40. It recommends daily dietary fluoride supplements for children from birth to age 16 years who are at “high” risk for developing dental caries and whose primary source of drinking water is deficient in fluoride; “high risk” status can be determined using risk assessment tools developed by one of several professional health organizations. Dietary fluoride supplementation is not recommended when water fluoridation levels are greater than 0.6 ppm F11. The Centers for Disease Control and Prevention recommend that clinicians counsel parents about appropriate use of fluoridated toothpastes, especially in children age 2 years and younger; prescribe fluoride supplements to children at high risk for dental caries whose drinking water lacks adequate fluoridation; and limit the use of high-concentration fluoride products, such as varnish and gel, to high-risk individuals37. The American Academy of Pediatric Dentistry states that fluoride dietary supplements should be considered for children at risk for caries who drink fluoride-deficient (<0.6 ppm) water. It also states that children at increased risk for caries should receive a professional fluoride treatment (e.g., 5% sodium fluoride varnish or 1.23% acidulated phosphate fluoride) every 6 months41. The American Academy of Family Physicians is updating its recommendations on the subject.