preventing dental caries in children 5 years ... -...

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 by guest on June 4, 2018www.aappublications.org/newsDownloaded from

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.

REVIEW ARTICLE

PEDIATRICS Volume 132, Number 2, August 2013 333 by guest on June 4, 2018www.aappublications.org/newsDownloaded from

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.


http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2013-1469/-/DCSupplemental




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

REVIEW ARTICLE





TABLE1

Quality

Ratings

ofRandom

ized

ControlledTrials

Author,

Year,Title

Random

ization

Adequate?

Allocation

Concealment

Adequate?

Groups

Similar

atBaseline?

Eligibility

Criteria

Specified?

Outcom

eAssessors

Masked?

Care

Provider

Masked?

Patient

Masked?

Reportingof

Attrition,

Crossovers,

Adherence,

and

Contam

ination

Loss

ToFollow-up:

Differential/

High

Intention-

To-Treat

Analysis

Postrandom

ization

Exclusions

Outcom

esPrespecified

Funding

Source

External

Validity

Quality

Rating

Alam

oudietal

201223

Unclear

Yes

Unclear

Yes

Unclear

NoNo

Yes

Yes(veryhigh)

Yes

Yes

Yes

TheDeanship

ofScientific

Research,King

Abdulaziz

University,Jeddah,

SaudiArabia

(ProjectNo.429/

011-9)

Fair

Poor

Effectsof

xylitolon

salivary

mutans

Streptococcus,

plaque

level,

andcaries

activity

inagroupof

Saudim

other-

child

pairs

Davies

etal2007

24Not random

ized

Unclear

Yes

Yes

Unclear

Unclear

Unclear

NoYes

NoNo

Yes

NationalH

ealth

ServiceResearch

andDevelopm

ent

Program

forPrimary

DentalCare

Fair

Poor

Challenges

associated

with

theevaluation

ofadental

health

prom

otion

programin

adeprived

urbanarea

Davies

etal2005

25

Astaged

intervention

dentalhealth

prom

otion

programto

reduce

early

childhood

caries

Kovarietal200326

NRNR

Unclear

Yes

Unclear

NoNo

Yes

NoYes

NoYes

Notreported

Limited

Fair

Useofxylitol

chew

inggumin

daycare

centers:

afollow-up

studyin

Savonlinna,

Finland


TABLE1

Continued

Author,

Year,Title

Random

ization

Adequate?

Allocation

Concealment

Adequate?

Groups

Similar

atBaseline?

Eligibility

Criteria

Specified?

Outcom

eAssessors

Masked?

Care

Provider

Masked?

Patient

Masked?

Reportingof

Attrition,

Crossovers,

Adherence,

and

Contam

ination

Loss

ToFollow-up:

Differential/

High

Intention-

To-Treat

Analysis

Postrandom

ization

Exclusions

Outcom

esPrespecified

Funding

Source

External

Validity

Quality

Rating

Kressin

etal2009

27Not random

ized

Yes

Yes

Yes

NoNo

Yes

Yes

NoYes

NoYes

NIH/NIDCR

andVA

Fair

Fair

Pediatric

clinicians

can

helpreduce

ratesofearly

childhood

caries:effects

ofapractice-

based

intervention

Lawrenceetal

200828

Yes

Unclear

Yes

Yes

Yes

NoNo

Yes

No/No

Yes

NoYes

TheInstituteof

AboriginalPeoples’

Health

ofthe

Canadian

Institutes

ofHealth

Research

(Grant

#MOP-

64215)

andthe

TorontoHospitalfor

Sick

Children

Foundation(Grant

#XG

03-067)

Limited:

Aboriginal

communities

inruralCanada

Good

A2-ycommunity-

random

ized

controlledtrial

offluoride

varnishto

preventearly

childhood

caries

inAboriginal

children

Oscarson

etal

2006

29NR

NRYes

Yes

Yes

NoNo

Yes

NoYes

NoYes

Grantsfrom

Count

ofVasterbotten,

thePatient

RevenueFund

forDental

Prophylaxis

andthe

Swedish

DentalSociety

Fair

Fair

Influenceof

alowxylitol-

dose

onmutans

streptococci

colonization

andcaries

developm

entin

preschool

children

REVIEW ARTICLE


TABLE1

Continued

Author,

Year,Title

Random

ization

Adequate?

Allocation

Concealment

Adequate?

Groups

Similar

atBaseline?

Eligibility

Criteria

Specified?

Outcom

eAssessors

Masked?

Care

Provider

Masked?

Patient

Masked?

Reportingof

Attrition,

Crossovers,

Adherence,

and

Contam

ination

Loss

ToFollow-up:

Differential/

High

Intention-

To-Treat

Analysis

Postrandom

ization

Exclusions

Outcom

esPrespecified

Funding

Source

External

Validity

Quality

Rating

Sekietal201130

NoNo

Unclear(dfs

index)

Yes

Yes

NoNo

Yes

Yes

Yes

Yes

Yes

TheUemuraFund,

NihonUniversity

SchoolofDentistry,

agranttoprom

ote

multidisciplinary

research

projects

from

theMinistryof

Education,Science,

Sports,Culture

and

Technology,Japan

Fair

Poor

Effectof

xylitolgum

onthe

levelof

oralmutans

streptococci

of preschoolers:

block-

random

ized

trial

Sladeetal201131

Yes

Yes

Yes;some

differencein

fluoridation

status

Yes

NoNo

NoYes

No/No

Yes

NoYes

Projectgrant

#320858from

the

AustralianNational

Health

andMedical

Research

Council

Limited:

Aboriginal

communities

inruralAustralia

Good

Effectofhealth

prom

otionand

fluoride

varnishon

dentalcaries

among

Australian

Aboriginal

children:

results

from

acommunity-

random

ized

controlledtrial

Weinsteinetal

200132

Yes

Unclear

Unclear

Yes

Unclear

Unclear

Unclear

Yes

Yes/Yes

Yes

NoYes

GrantNo.R03

DE-

012138

from

NIDCR/NIH

Head

Start

program

Fair

Equivalence

between

massive

versus

standard

fluoride

varnish

treatm

entsin

high

caries

childrenaged

3-5y


TABLE1

Continued

Author,

Year,Title

Random

ization

Adequate?

Allocation

Concealment

Adequate?

Groups

Similar

atBaseline?

Eligibility

Criteria

Specified?

Outcom

eAssessors

Masked?

Care

Provider

Masked?

Patient

Masked?

Reportingof

Attrition,

Crossovers,

Adherence,

and

Contam

ination

Loss

ToFollow-up:

Differential/

High

Intention-

To-Treat

Analysis

Postrandom

ization

Exclusions

Outcom

esPrespecified

Funding

Source

External

Validity

Quality

Rating

Weinsteinetal

2009

33Yes

Unclear

No;m

eandm

fswere

notb

alanced

Yes

Yes

Unclear

Unclear

Yes

No/No

Yes

NoYes

GrantsNo.

R01DE14403

and

U54DE14254

from

NIDCR,NIH

Head

Start

program

Fair

Random

ized

equivalence

trialof

intensiveand

semiannual

applications

offluoride

varnishinthe

primary

dentition

Weintraub

etal

2006

34Yes

Yes

Yes;stated

noimbalances

apparent

Yes

Yes

NoYes

Yes

Yes/No

Yes

NoYes

USPHSResearch

GrantsP60DE13058

andU54DE142501

from

theNIDCRand

theNCMHD

,NIH,

andby

theUCSF

Departmentof

Preventiveand

RestorativeDental

Sciences

Limited:

“Underserviced”

community

inUnitedStates;

allnonwhite

Fair

Fluoride

varnish

efficacy

inpreventing

earlychildhood

caries

Zhan

etal201235

Yes

Unclear

Yes

Yes

Yes

Yes

Yes

Yes

No/Yes

(23%

in1group)

Yes

NoYes

California

Societyof

PediatricDentistry

Foundation,a

GraduateScientific

Research

Award

from

American

Academ

yof

PediatricDentistry,

andNIH/NIDCR

grantU54

DEO19285

SingleCenter

Fair

Effectsof

xylitol

wipes

oncarcinogenic

bacteriaand

caries

inyoung

children

dfs,decayedfilledsurfaces;NCM

HD,NationalCenteron

Minority

HealthandHealthDisparities;NIDCR,NationalInstituteofDentalandCraniofacialResearch;NIH,NationalInstitutes

ofHealth;UCSF,UniversityofCaliforniaSanFrancisco;USPHS,United

States

PublicHealth

Service;VA,VeteransAffairs;NR

,not

reported.

REVIEW ARTICLE


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


TABLE2

Summaryof

TopicalFluoride

PreventiveTreatm

ents

Author,Year,

Quality

StudyDesign

Interventions

Country;Setting;

FluoridationStatus

Ageat

Enrollm

ent

Sample

Size

F-U,y

MeanCaries

Increm

ent

AbsoluteReductionin

Caries

Increm

ent

ReductioninCaries

Increm

ent

OtherDentalCaries

Outcom

es

Lawrenceetal

2008

28Good

ClusterRCT(20

clusters)

A:0.3–0.5mL5%

sodium

fluoride

varnish

appliedtofullprimary

dentition

every6mo

Canada;RuralAboriginal

communities;W

ater

fluoridationstatus:No

fluoridation

2.5y

1146

2dm

fs2.4(1.8)a

18%(29%

)aAversus

B

B:No

fluoride

varnish

A:11.0(4.3)a

Dentalcaries

inaboriginal

cohort:72%

(595/832)vs

75%(247/328),adjusted

OR0.72

(95%

CI0.42–1.25);

NNT26

B:13.4(6.1)a

Dentalcaries

inthosecaries-

free

atbaseline:44%(157/

354)

vs58%(73/126);

adjusted

OR0.63

(95%

CI0.33–1.1);NNT

7.4

P=.24(P=.18)

a

Sladeetal2011

31

Good

ClusterRCT(30

clusters)

A:0.25

mLof5%

sodium

fluoride

varnishto

maxillaryanterior

teeth/molars,

mandibularmolars/

incisors

every6mo,

education/advice

tocaregiverwith

toothbrush/paste

provided,com

munity

oralhealth

prom

otion

program

Australia;Rural

Aboriginal

communities;W

ater

fluoridationstatus:

81%to92%had

,0.6ppmF

2.8y

666

2dm

fs2.3

24%

B:No

interventions

A:7.3

B:9.6b

P,

.05

Weinsteinetal

2001

32Fair

RCTwith

3treatm

ent

groups

A:Oneapplicationof5%

fluoride

varnishat

baselineand6mo

UnitedStates;HeadStart

programs;Water

fluoridationstatus:NR

3–5y

111

1Clinicaldm

fsA:

4.6

Notcalculated

Notcalculated

B:Threeapplications

of5%

fluoride

varnish

within2wkofbaseline

B:3.2

C:Threeapplications

of5%

fluoride

varnish

within2wkofbaseline

and6mo

C:4.7

P=.65

Radiographic

meandm

fsA:0.9

B:0.5

C:0.1

P=.28

REVIEW ARTICLE


TABLE2

Continued

Author,Year,

Quality

StudyDesign

Interventions

Country;Setting;

FluoridationStatus

Ageat

Enrollm

ent

Sample

Size

F-U,y

MeanCaries

Increm

ent

AbsoluteReductionin

Caries

Increm

ent

ReductioninCaries

Increm

ent

OtherDentalCaries

Outcom

es

Weinsteinetal

2009

33Fair

RCTwith

2treatm

ent

groups

A:One5%

fluoride

varnish

treatm

entand

2placebotreatm

ents

every6mo

UnitedStates

55–56

mo

515

3dm

fs2.4

24%

Adjusted

rateratio

ofnew

toothdecayinprimary

surfaces

1.13

(95%

CI0.94–1.37)

B:Onesetof3,5%fluoride

varnishtreatm

ents

over

2wkonce

per

year

and3placebo

treatm

entsover

2wk,

6molater

Recruitm

entsetting:

Head

Startp

rogram

sA:7.4

Waterfluoridationstatus:

NR(Yakimavoters

approved

fluoridation

in1999)

B:9.8

P=.001

Weintraub

etal

2006

34,cFair

RCT

A:0.1mLof5%

sodium

fluoride

varnishper

arch

appliedtwiceper

year

with

4intended

applications

UnitedStates;Fam

ilydentalcenter

and

publichealth

center

servingprimarily

low-

income,underserved

HispanicandChinese

populations

1.8y

280

2d 2

+fsd

1.0

59%(A

+Bvs

C)Avs

Bvs

C

B:0.1mLof5%

sodium

fluoride

varnishper

arch

appliedonce

per

year

with

2intended

applications

Waterfluoridationstatus:

Approximately1ppm

A:0.7

Caries

lesionsat12

mo:13%

(11/83)vs

15%(13/86)vs

29%(27/92);RR

0.45

(95%

CI0.24–0.85);NN

T7forAvs

Cand0.52

(95%

CI0.28–

0.93);NN

T8forBvs

CC:No

fluoride

varnish

B:0.7

Caries

lesionsat24

mo:4.3%

(3/70)

vs14%(10/69)vs

24%(15/63);RR

0.18

(95%

CI0.06–0.59);NN

T6forAvs

Cand0.61

(95%

CI0.30–

1.26);NN

T11

forBversus

CC:1.7

P,

.01forAor

Bvs

C

ANOVA,analysisofvariance;CI,confidenceinterval;d

2+fs,num

berofdecayedor

filledsurfaces;F-U,follow-up;NN

T,numberneeded

totreat;NR

,not

reported;RCT,randomized

controlledtrial;RR,relativerisk.

aChildrencaries-free

atbaseline.

bAdjusted.

cInthefluoride

varnishtreatm

entgroup,somechildrenreceived

aplacebovarnishinsteadoffluoride

varnishduetoprotocolerrors.

dParticipantswerecaries-free

atbaseline.


TABLE3

Summaryof

Xylitol

PreventiveTreatm

ents

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

Alam

oudietal

2012

23Poor

RCT

A:Xylitolchew

able

tablets(1.2g,84%

xylitol)chew

edfor

5min3tim

esdaily

SaudiArabia;

Recruitm

ent

setting:Well-infant

clinicsanddental

clinics;Water

fluoridationstatus:

Notreported

2–5y

341.5

dmft

3.6

82%

Avs

B

B:Fluoride

varnish,

every6mo

throughout

study

A:0.8

dmftatbaseline:8.4vs

10.3

(P=.19)

dmftat18

mo:

9.2vs

14.7(P

=.001)

B:4.4

P=notreported

Kovarietal

2003

26,aFair

ClusterRCT(11

clusters)

A:65%Xylitolgum3

times

perday,

chew

edfor3–5min,

fortotalof2.5g/d

Finland;Recruitm

ent

setting:daycare

centers;Water

fluoridationstatus:

Notreported

3–6y

786

3–6

Notreported

Notreported

Notreported

Avs

B

B:Toothbrushing

with

0.05%NaF

toothpasteafter

lunch

Caries

at7yold:31%(98/

316)

vs35%(149/427),

RR0.88

(95%

CI0.72–1.10)

Caries

at9yold:43%(133/

310)

vs51%(221/434),

RR0.84

(95%

CI0.72–0.99)

dmft:1.1vs

1.0at

7y,1.2vs

1.6at9y

Oscarson

etal

2006

29Fair

RCT

A:One0.48-gxylitol

tabletatbedtime

afterbrushing

for

6mo;then

1tablet

twicedaily

toage3y

and6mo

Sweden;Recruitm

ent

setting:Public

dentalclinic;W

ater

fluoridationstatus:

Notreported

25mo

115

2dm

fs0.42

52%

Avs

B

B:No

tablets

A:0.38

Dentalcaries:18%

(10/55)

vs25%(16/63),OR

0.65

(95%

CI0.27–1.59)

B:0.80

P.

.05

Sekietal2011

30

Poor

Cluster,non–

random

ized

controlledclinical

trial(3clusters)

A:Xylitolchew

inggum

(100%xylitol,1.33g);

1pelletchew

ed5

min4tim

esdaily

Japan;Recruitm

ent

setting:Preschool;

Water

fluoridation

status:Notreported

(statesfluoridation

“limited”

inJapan)

66%–72%

4yold

161

1dfs

0.1

3%Avs

B

B:No

intervention

A:3.3

Developm

entofcariesfrom

baseline–6mo:1.7vs

1.6

(P.

.05)

B:3.4

Developm

entofcariesfrom

6mo–1y:1.6vs

1.8

(P.

.05)

P.

.05

REVIEW ARTICLE


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.


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


TABLE4

Summaryof

Evidence

MainFindings

From

2005

USPSTF

Review

NumberandType

ofStudiesIdentified

forUpdateOverallQualitya

Limitations

Consistency

Applicability

SummaryofFindings

KeyQuestion1.Howeffectiveisoralscreening(including

risk

assessment)by

theprimarycare

clinicianinpreventingdentalcaries

inchildren,5yofage?

Noevidence

Nostudies

Nostudies

Nostudies

Nostudies

Norandom

ized

trialorobservational

studycomparedclinicaloutcom

esbetweenchildren,5yofage

screened

andnotscreened

byprimarycare

clinicians.

KeyQuestion2a.How

accurateisscreeningby

theprimarycare

clinicianinidentifying

children,5yofagewho

have

cavitatedor

noncavitatedcaries

lesions?

Onestudyfoundpediatrician

exam

inationafter4hoforal

healtheducationassociated

with

asensitivityof1.0andspecificity

of0.87

foridentifying

nursing

caries

inchildren18

to36

moof

age.

Onecohortstudy

Evidence

limitedtotwo

studies,onegood-quality

N/A

Studyconductedinaprimarycare

setting

Onestudyfoundprimarycare

pediatrician

exam

inationafter2

hof

oralhealth

educationassociated

with

asensitivityof0.76

for

identifying

achild

with

1or

more

cavitiesand0.63

foridentifying

children,36

moofageinneed

ofadentalreferral,com

paredwith

apediatricdentistevaluation.

Overallquality:Fair

KeyQuestion2b.How

accurateisscreeningby

theprimarycare

clinicianinidentifying

children,5yofagewho

areatincreasedrisk

forfuture

dentalcaries?

Noevidence

Nostudies

Nostudies

Nostudies

Nostudies

Nostudyevaluatedtheaccuracy

ofgeneralassessm

entoruseofrisk

assessmenttoolsby

primarycare

clinicians

toidentifychildrenat

increasedrisk

forfuture

dental

caries.

KeyQuestion3.Whatare

theharm

soforalhealth

screeningby

theprimarycare

clinician?

Noevidence

Nostudies

Nostudies

Nostudies

Nostudies

Norandom

ized

trialorobservational

studycomparedharm

sbetween

children,5yofagescreened

and

notscreenedby

primarycare

clinicians.

KeyQuestion4.Howeffectiveisparentalor

caregiver/guardian

oralhealth

educationby

theprimarycare

clinicianinpreventingdentalcaries

inchildren,5yofage?

Noevidence

1random

ized

trial,1nonrandomized

trial

Nonrandomized

design,highattrition,

failure

toadjustforconfounders.

Moderate

inconsistency

Educationevaluatedas

partof

amultifactorialintervention

Notrialspecifically

evaluatedan

educationalorcounseling

interventiontopreventd

ental

caries.Twostudiesfound

multifactorialinterventions

that

included

aneducationalcom

ponent

associated

with

decreased

incidenceor

prevalence

ofcavities

inunderservedchildren,5yof

age.

Overallquality:Poor


TABLE4

Continued

MainFindings

From

2005

USPSTF

Review

NumberandType

ofStudiesIdentified


Limitations

Consistency

Applicability

SummaryofFindings

KeyQuestion5.Howeffectiveisreferralby

aprimarycare

clinicianto

adentistinpreventingdentalcaries

inchildren,5yofage?

Noevidence

1cohortstudy

Studynotd

esignedtodeterm

ine

whether

aprimarycare

referral

was

thesource

oftheinitial

preventivevisit

N/A

Medicaidpopulation,higher-risk

children

Nostudydirectlyevaluatedtheeffects

ofreferralby

aprimarycare

cliniciantoadentistoncaries

incidence.Onestudyfoundafirst

dentalpreventivevisitafter18moof

ageinchildrenwith

existingdental

diseaseassociated

with

increased

risk

ofsubsequent

dental

procedures

comparedwith

afirst

visitbefore18moofage,butw

asnot

designed

todeterm

inereferral

source.

Overallquality:Poor

KeyQuestion6.Howeffectiveispreventivetreatm

entw

ithdietaryfluoride

supplementationinpreventingdentalcaries

inchildren,5yofage?

Sixtrialsofdietaryfluoride

supplements.One

random

ized

trialand

4othertrialsfoundoral

fluoride

supplementationin

settings

with

water

fluoridation

levels,

0.6ppmFassociated

with

decreasedcaries

incidence

versus

nofluoridation(rangesof

48%–72%forprimaryteethand

51%–81%forprimarytooth

surface).

Nostudies

Limitations

inpreviouslyreview

edstudiesincludeuseof

nonrandomized

design,not

controlling

forconfounders,

inadequateblinding

andhigh

orunreported

attrition

N/A

Nostudies

Weidentified

nonewtrialson

the

effectsofdietaryfluoride

supplementationinchildren,5yof

ageon

dentalcaries

incidence.

Overallquality:Fair


entw

ithtopicalfluoride

application(fluoride

varnish)

inpreventingdentalcaries

inchildren,5yofage?

Threerandom

ized

trialsfound

fluoride

varnishmoreeffective

than

nofluoride

varnishin

reducing

caries

incidence

(percent

reduction37%–63%,

with

anabsolutereductioninthe

meannumberofcavitiesper

child

of0.67–1.24

peryear.)

3random

ized

trialsb ;

High

loss

tofollow-up,failure

todescribe

adequateblinding,and

failure

todescribe

adequate

allocationconcealment

Consistent

Ruralsettings

with

inadequate

fluoridationor

lowsocioeconomic

status

settings

Threerandom

ized

trialspublished

sincetheprevious

review

found

fluoride

varnishmoreeffectivethan

nofluoride

varnishinreducing

caries

incidence(percentreduction

incaries

increm

ent18%

–59%).

Othertrialsevaluatedmethods

oftopicalfluoride

applicationnot

used

intheUnitedStates

orcompareddifferent

dosesor

frequenciesoftopicalfluoride.

Overallquality:Fair

REVIEW ARTICLE


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


Limitations

Consistency

Applicability

SummaryofFindings


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.


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DOI: 10.1542/peds.2013-1469 originally published online July 15, 2013; 2013;132;332Pediatrics

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