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 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. AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmakers— patients and clinicians, health system leaders, and policymakers—make more informed decisions and improve the quality of health care services. Dental Caries Prevention: The Physician’s Role in Child Oral Health Systematic Evidence Review Submitted to: Agency for Healthcare Research and Quality 540 Gaither Road Rockville, Maryland 20850 Submitted by: RTI International 3040 Cornwallis Road P.O. Box 12194 Research Triangle Park, North Carolina 27709 Contract No. 290-97-0011 Dental Caries Prevention: The Physician’s Role in Child Oral Health Systematic Evidence Review Agency for Healthcare Research and Quality Contract #290-97-0011, Task Order No. 3 Technical Support for the U.S. Preventive Services Task Force James D. Bader, DDS, MPH* Gary Rozier, DDS, MPH † Russell Harris, MD, MPH ‡ Kathleen N. Lohr, PhD § * UNC School of Dentistry and Sheps Center for Health Services Research, Chapel Hill, NC. † UNC School of Public Health, Chapel Hill, NC ‡ UNC Sheps Center for Health Services Research, Chapel Hill, NC § RTI International, Research Triangle Park, NC and UNC School of Public Health, Chapel Hill, NC Preface The Agency for Healthcare Research and Quality (AHRQ) sponsors the development of Systematic Evidence Reviews (SERs) through its Evidence-based Practice Program. With guidance from the U.S. Preventive Services Task Force * (USPSTF) and input from Federal partners and primary care specialty societies, the Evidence-based Practice Center at Oregon Health Sciences University systematically reviews the evidence of the effectiveness of a wide range of clinical preventive services, including screening, counseling, and chemoprevention, in the primary care setting. The SERs—comprehensive reviews of the scientific evidence on the effectiveness of particular clinical preventive services—serve as the foundation for the recommendations of the USPSTF, which provide age- and risk-factor-specific recommendations for the delivery of these services in the primary care setting. Details of the process of identifying and evaluating relevant scientific evidence are described in the “Methods” section of each SER. The SERs document the evidence regarding the benefits, limitations, and cost-effectiveness of a broad range of clinical preventive services and will help further awareness, delivery, and coverage of preventive care as an integral part of quality primary health care. AHRQ also disseminates the SERs on the AHRQ Web site (http://www.ahrq.gov/clinic/uspstfix.htm ) and disseminates summaries of the evidence (summaries of the SERs) and recommendations of the USPSTF in print and on the Web. These are available through the AHRQ Web site and through the National Guideline Clearinghouse (http://www.ngc.gov) . We welcome written comments on this SER. Comments may be sent to: Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 3000, Rockville, MD 20850, or e-mail uspstf@ahrq.gov. Carolyn M. Clancy, M.D. Jean Slutsky, P. A., M.S.P.H. Director Acting Director Agency for Healthcare Research and Quality Center for Outcomes and Evidence Agency for Healthcare Research and Quality * The USPSTF is an independent panel of experts in primary care and prevention first convened by the U.S. Public Health Service in 1984. The USPSTF systematically reviews the evidence on the effectiveness of providing clinical preventive services including screening, counseling, and chemoprevention in the primary care setting. AHRQ convened the current USPSTF in November 1998 to update existing Task Force recommendations and to address new topics. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or othe r clinical service. Dental Disease Prevention: The Physician’s Role in Child Oral Health i Contents Chapter 1. Introduction………………………………………………………… 1 Epidemiology………………………………………………………………1 Prevention………………………………………………………………….4 Guidelines for Prevention of Dental Caries…………………………….5 Access…………………………………………………………………… 7 Analytic Framework and Key Questions……………………………….10 Chapter 2. Methods………………………………………………………………14 Studies Involving Primary Care Physicians………………………… 14 Studies in the Dental Literature………………………………………….15 Chapter 3. Results……………………………………………………………… 17 Accuracy of Screening by Primary Care Clinicians……………………17 Identifying Needed Referrals……………………………….……17 Effectiveness of Primary Care Clinician Referral to a Dentist…………………………………………………… … 19 Effectiveness of Fluoride Supplementation…………………… 20 Effectiveness of Professional Fluoride Application…………….26 Effectiveness of Counseling for Caries Prevention…………….30 Chapter 4. Discussion…………………………………………………………… 33 Screening Accuracy……………………………………………………… 33 Referral Effectiveness…………………………………………………… 34 Effectiveness of Fluoride Supplementation…………………………… 34 Appropriateness of Supplementation Decision………………….34 Parental Adherence……………………………………………… 35 Effectiveness of Supplements…………………………………….35 Effectiveness of Fluoride Application…………………………………….38 Appropriateness of Application Decision……………………… 38 Effectiveness of Counseling………………………………………………40 Adherence to Recommendations and Caries Prevention…… 40 Other Issues: Pediatric Medications Containing Sugar……… 41 A Research Agenda……………………………………………….42 References…………………………………………………………………………45 Figure 1. Dental Care for Young Children from Primary Care Physicians: Analytic Framework……………………… 54 Table 1. Search Results on Studies of Primary Care Providers’ Involvement in Child Oral Health…………………………………………… 55 Table 2 Sources of Data for Collateral Evidence from the Dental Literature………………………………………………………56 Dental Disease Prevention: The Physician’s Role in Child Oral Health ii Table 3. Studies Reporting Screening Accuracy for Primary Care Providers……………………………………………………57 Table 4. Risk Indicators for Dental Caries in Children Suggested for Use in Dental Practice…………………………………………… ……………….58 Table 5. Studies Reporting Referral Effectiveness………………………….59 Table 6. Physicians’ Knowledge of and Behavior Regarding Fluoride Supplementation………………………………………………………………60 Table 7A. Effects of Fluoride Supplements on Primary Teeth: Study Design Characteristics…………………………………………………61 Table 7B. Effects of Fluoride Supplements on Primary Teeth: Study Results………………………………………………………………… 62 Table 8A. Clinical Studies of Fluoride Varnish Applied to Primary Teeth: Study Design………………………………………………………………… 63 Table 8B. Clinical Studies of Fluoride Varnish Applied to Primary Teeth: Results………………………………………………………………….65 Table 9. Summary of Systematic Reviews of the Effectiveness of Oral Health Promotion and Education…………………………………….67 Appendix A. Acknowledgements………………………………………………A1 Appendix B……………………………………………………………………… B1 Dental Disease Prevention: The Physician’s Role in Child Oral Health 1 Chapter 1. Introduction Issues of oral health in children revolve almost exclusively around dental caries. In the United States, dental caries is the most common chronic childhood disease, 1 and its treatment is the most prevalent unmet health need in children. 2 A substantial portion of caries lesions can be prevented; indeed, the incidence of this disease has declined among school-age children and adults in the past three decades. However, incidence among preschool children has not declined at a similar rate over this same time period. Epidemiology Dental caries is an infectious disease that can occur when cariogenic bacteria colonize a tooth surface in the presence of dietary carbohydrates, especially refined sugars. The bacteria metabolize the carbohydrates, producing lactic acid, which over time demineralizes the tooth structure. 3 The earliest visible manifestation of dental caries is the appearance of a demineralized area on the tooth surface, which presents either as a small white spot on a smooth surface or a pit or fissure. At this stage, a caries lesion is usually reversible. If oral conditions do not change, demineralization will continue with the eventual result that the tooth surface loses its natural contour and a “cavity” develops. At this stage, restorative treatment is necessary to prevent the continuation of the caries process, which if left untreated will eventually result in pulpitis and ultimately tooth loss. Progression of individual caries lesions is typically slow, but it can be extremely rapid in a small proportion of individuals and especially in primary teeth, which have thinner enamel. Because dental caries is a chronic disease of microbial origin, modified by diet, the elimination Dental Disease Prevention: The Physician’s Role in Child Oral Health 2 of active caries lesions through treatment does not necessarily mean that the disease has been eradicated. An individual’s risk for dental caries can change with time as etiologic factors change, leading to new caries events around already treated lesions or on previously unaffected tooth surfaces. Dental caries can occur soon after eruption of the primary teeth, starting at 6 months of age. The most recent national survey (1988-1994) indicated that 52% of children 5 to 9 years of age have experienced dental caries; 4 of children 2 to 5 years of age, 18.7% have at least 1 primary tooth with untreated decay. 5 Referred to as early childhood caries (ECC), dental caries in preschool children can take several forms. The most severe form has a pattern of early initial attack on the maxillary incisors with the attack continuing on other teeth as they erupt. 6 Dental caries incidence begins in the permanent teeth at about 6 years with the eruption of central incisors and first molars. Among children 5 to 11 years of age, 26% have experienced one or more lesions in permanent teeth; this proportion increases to 67% among adolescents 12 to 17 years of age. 7 Dental caries is unequally distributed among the population. Caries incidence, prevalence, and severity is greater in minority and economically disadvantaged children. 2,4,5,8 Among children 1 to 2 years of age examined in the most recent national survey, all who had obvious dental caries in the maxillary incisors were in the group with incomes at or below 200% of the federal poverty line. 9 Among children 2 to 5 years of age, those in families at or below the poverty level are 106% more likely to have experienced dental caries than children in families with incomes above the poverty level. 5 At this same age, black children have 43% more untreated carious primary teeth than white children, and children at or below the federal poverty line have 138% more than children above the poverty line. 10 Dental Disease Prevention: The Physician’s Role in Child Oral Health 3 Dental caries in primary teeth can has both short- and longer-term negative consequences. Caries lesions often cause pain because they can progress rapidly in primary teeth and involve the pulp before they are either detected or treated. About 1 in 10 children 2 to 17 years of age and 1 in 5 children from low-income families made dental visits because they were in pain or something was bothering them. 11 Regardless of their degree of progression, lesions cavitated into dentin require reparative treatment or tooth extraction; both are frequently traumatic experiences for young children. Young children with untreated, symptomatic carious teeth often present to emergency departments of hospitals for their first dental visit. 12 Also, untreated caries lesions in young children may be associated with failure to thrive, 13 although evidence is conflicting regarding this association. 14 Social outcomes of dental caries in young children are poorly documented, but children 5 to 7 years of age in the United States have been estimated to lose more than 7 million school hours annually because of dental problems and/or visits. 15 Untreated caries typically is cited as leading to increased infections, dysfunction, poor appearance, and low self-esteem, 16 but most of these associations stem from conventional wisdom rather than observational studies. Longer-term consequences of dental caries in primary teeth include an increased probability of caries in the permanent dentition 17,18 and possible loss of arch space. Lack of treatment for caries in primary teeth will often result in the premature loss of the primary teeth, especially molars, which are at risk for the longest period. Premature loss of primary molars can lead to loss of arch space as the first permanent molars drift into the missing tooth spaces. 19 The result can be crowding of the permanent teeth, the severity of which depends on the amount of lost space. Anterior tooth crowding affects aesthetics and may necessitate orthodontic treatment for correction. [...]... to utilize in this preschool population Thus, a sound theoretical basis exists for a focus on the role of physicians in the prevention of dental caries in preschool children This review is not intended to suggest that the role of the physician should supplant the role of the dentist in maintaining the oral health of preschool children Rather, the fundamental assumption of the review is that the responsibility... or questionnaire, and they may already be available through health history and behavioral data that Dental Disease Prevention: The Physician’s Role in Child Oral Health 19 are routinely collected Nevertheless, we found no studies that examined PCC accuracy in identifying children who displayed one or more risk indicators using these or other risk indicators, with the exception of the studies summarized... fluorides other than fluoride varnish in young children and the absence of clinical trials of the caries preventive effectiveness of other products, the focus of this review is on fluoride varnish alone Dental Disease Prevention: The Physician’s Role in Child Oral Health 27 Fluoride varnish was developed in Europe during the 1960s with the aim of prolonging the contact time between fluoride and the tooth... management of a child s oral health is shared among PCCs and dentists, and major Dental Disease Prevention: The Physician’s Role in Child Oral Health 10 responsibility is transferred from a PCC to a dentist at a point in time arranged jointly by the PCC, parents, and dentist This report represents a departure from the chapter on Oral Health that appeared in the 1996 edition of the Guide to Clinical and... a well -child care provided by the pediatrician Dental Disease Prevention: The Physician’s Role in Child Oral Health 28 Parental Agreement We identified no studies describing PCC effectiveness in obtaining parental agreement for in- office application of topical fluoride We also were unable to locate any study describing the effectiveness of dentists in obtaining such permission Again, only indirect... caries in primary teeth The table updates a systematic review on the topic completed for the National Institutes of Health (NIH) Caries Consensus Development Conference.77 The original review included 7 papers retrieved from MEDLINE for 1966 through 2000 having primary tooth caries increments in both experimental and control groups In the updated review, Dental Disease Prevention: The Physician’s Role in. .. Questions The analytic framework for this review (Figure 1) represents a risk-based approach to the prevention and management of dental caries It begins with a child s visit to a PCC, presumably a well -child visit The PCC screens the child for both the presence of dental caries and risk indicators for dental caries Depending on the results of the screening (either identification of suspected caries lesions... PCC may also undertake counseling This arm as well as the outcomes of treatment by dental professionals, are shown by dotted lines, indicating that we did not evaluate them in this review Dental Disease Prevention: The Physician’s Role in Child Oral Health 11 The framework is intended to outline general types of interventions that PCCs provide and that are appropriate to children between birth and 5... preventive intervention for dental caries presumably would have reduced or eliminated the incidence of disease Yet, many children do not make a dental visit until well Dental Disease Prevention: The Physician’s Role in Child Oral Health 9 after the disease has progressed beyond the reversible stage Also, those least likely to make an early dental visit are those most likely to have dental caries Physicians... use and minimally effective with respect to tooth brushing Prevention of Dental Caries We found no study assessing the effectiveness of a PCC-supplied counseling intervention in preventing dental caries We examined 4 published systematic reviews of the effectiveness of oral heath promotion and dental health education from the dental literature One of these reviews included a metaanalysis for an intermediate . preschool children. This review is not intended to suggest that the role of the physician should supplant the role of the dentist in maintaining the oral health. than children above the poverty line. 10 Dental Disease Prevention: The Physician’s Role in Child Oral Health 3 Dental caries in primary teeth can