TABLE 4

Summary of Evidence

Main Findings From 2005 USPSTF ReviewNumber and Type of Studies Identified for Update Overall QualityaLimitationsConsistencyApplicabilitySummary 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 evidenceNo studiesNo studiesNo studiesNo studiesNo randomized trial or observational study compared clinical outcomes between children <5 y of age screened and not screened by primary 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 oral health education associated with a sensitivity of 1.0 and specificity of 0.87 for identifying nursing caries in children 18 to 36 mo of age.One cohort studyEvidence limited to two studies, one good-qualityN/AStudy conducted in a primary care settingOne study found primary care pediatrician examination after 2 h of oral health education associated with a sensitivity of 0.76 for identifying a child with 1 or more cavities and 0.63 for identifying children <36 mo of age in need of a dental referral, compared with a 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 evidenceNo studiesNo studiesNo studiesNo studiesNo study evaluated the accuracy of general assessment or use of risk assessment tools by primary care clinicians to identify children at increased risk for future dental caries.
Key Question 3. What are the harms of oral health screening by the primary care clinician?
 No evidenceNo studiesNo studiesNo studiesNo studiesNo randomized trial or observational study compared harms between children <5 y of age screened and not screened by primary care clinicians.
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 evidence1 randomized trial, 1 nonrandomized trialNonrandomized design, high attrition, failure to adjust for confounders.Moderate inconsistencyEducation evaluated as part of a multifactorial interventionNo trial specifically evaluated an educational or counseling intervention to prevent dental caries. Two studies found multifactorial interventions that included an educational component associated with decreased incidence or prevalence of cavities in underserved children <5 y of age.
Overall quality: Poor
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 evidence1 cohort studyStudy not designed to determine whether a primary care referral was the source of the initial preventive visitN/AMedicaid population, higher-risk childrenNo study directly evaluated the effects of referral by a primary care clinician to a dentist on caries incidence. One study found a first dental preventive visit after 18 mo of age in children with existing dental disease associated with increased risk of subsequent dental procedures compared with a first visit before 18 mo of age, but was not designed to determine referral source.
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 randomized trial and 4 other trials found oral fluoride supplementation in settings with water fluoridation levels < 0.6 ppm F associated with decreased caries incidence versus no fluoridation (ranges of 48%–72% for primary teeth and 51%–81% for primary tooth surface).No studiesLimitations in previously reviewed studies include use of nonrandomized design, not controlling for confounders, inadequate blinding and high or unreported attritionN/ANo studiesWe identified no new trials on the effects of dietary fluoride supplementation in children <5 y of age on dental caries incidence.
Overall quality: Fair
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 effective than no fluoride varnish in reducing caries incidence (percent reduction 37%–63%, with an absolute reduction in the mean number of cavities per child of 0.67–1.24 per year.)3 randomized trialsb;High loss to follow-up, failure to describe adequate blinding, and failure to describe adequate allocation concealmentConsistentRural settings with inadequate fluoridation or low socioeconomic status settingsThree randomized trials published since the previous review found fluoride varnish more effective than no fluoride varnish in reducing caries incidence (percent reduction in caries increment 18%–59%). Other trials evaluated methods of topical fluoride application not used in the United States or compared different doses or frequencies of topical fluoride.
Overall quality: Fair
Key Question 6. How effective is preventive treatment with xylitol in preventing dental caries in children <5 y of age?
 No studies (not included in the prior review)4 randomized trials; 1 nonrandomizedbVariability in xylitol formulation and dosingSome inconsistencyChildren from settings in which water was not fluoridated or fluoridation limitedThree trials reported no clear effects of xylitol versus no xylitol on caries incidence in children younger than 5 y, with the most promising results from a small (n = 37) trial of xylitol wipes. One trial found no difference between xylitol and toothbrushing.
Overall quality: Fair
Key Question 7. What are the harms of specific oral health interventions for prevention of dental caries in children <5 y of age (parental or caregiver/guardian oral health education, referral to a dentist, and preventive treatments)?
 One systematic review of 14 observational studies found dietary fluoride supplementation in early childhood associated with increased risk of fluorosis; ORs ranged from 1.3–15.6 and prevalence ranged from 10%–67%.5 observational studies in an updated systematic reviewUse of retrospective parental recall to determine exposuresConsistentDoses of fluoride generally higher than currently recommendedWe identified no studies published since the updated systematic review on the association between early childhood ingestion of dietary fluoride supplements and risk of enamel fluorosis. Five new studies in an updated systemic review were consistent with previously reported findings in showing an association between early childhood ingestion of systemic fluoride and enamel fluorosis. Other than diarrhea reported in 2 trials of xylitol, harms were poorly reported in other trials of caries prevention interventions in children <5 y of age.
Overall quality: Fair
  • a Overall quality is based on new evidence identified for this update plus previously reviewed evidence.

  • b Five studies reported in the full evidence review18 but not reported in this article evaluated topical fluoride varnishes not commonly used in the United States,36,37 compared different dosing regimens of xylitol,38 or evaluated povidone-iodine39 or chlorhexidine varnish.40 N/A, not applicable.