Review and special article
Physicians' roles in preventing dental caries in preschool children: A summary of the evidence for the U.S. Preventive Services Task Force

https://doi.org/10.1016/j.amepre.2003.12.001Get rights and content

Abstract

Context

Almost 20% of children aged 2 to 5 years have untreated dental caries. Physician interventions to prevent and manage dental caries in preschool children could help address this common problem.

Objective

To review the evidence for effectiveness of five possible physician interventions— (1) screening and risk assessment, (2) referral, (3) provision of dietary supplemental fluoride, (4) application of fluoride varnish, and (5) counseling—for the prevention of dental caries for the U.S. Preventive Services Task Force.

Data sources

Articles from 1966 to 2001 addressing the effectiveness of primary care clinicians' interventions to prevent or manage dental caries were identified in MEDLINE. The evidence for effectiveness of supplemental fluorides, fluoride varnish, and counseling for caries prevention performed by dental personnel was also examined through existing and new systematic reviews.

Data synthesis

For most key questions related to the five interventions, the evidence for primary care clinician effectiveness was rated as poor owing to the scarcity of studies. Ten surveys of physicians' knowledge and behavior about fluoride supplementation provided fair evidence, suggesting that supplementation decisions were often made without consideration of other fluoride exposures. Reviews of the dental literature identified fair evidence supporting the effectiveness of both fluoride supplements and varnish, although information describing effectiveness and adverse outcomes of supplementation with the most recent dosage schedule is not available.

Conclusions

Evidence for the effectiveness of traditionally recommended primary care clinician interventions (screening, referral, counseling) to prevent dental caries in preschool children is lacking. There is fair evidence for the effectiveness of two fluoride-based interventions (fluoride supplementation and varnish) applicable in primary care practice. However, there is also fair evidence indicating that physicians' consideration of fluoride exposure is incomplete, thus increasing the risk for fluorosis among those prescribed supplements.

Introduction

I ssues of oral health in children revolve principally 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 need.2 Dental caries can occur soon after eruption of the primary teeth, starting at 6 months of age, and 19% of children aged 2 to 5 years have at least one primary tooth with untreated decay.3 Dental caries is unequally distributed among the population, with caries incidence, prevalence, and severity being greater among minority and economically disadvantaged children than among other groups.2, 3, 4, 5

A first dental visit when a child is approximately 1 year of age is now widely recommended.6 Data from the Medical Expenditures Panel Survey (MEPS) and the National Health and Nutrition Examination Survey (NHANES) indicate that 20%7 and 30%,8, 9 respectively, of the child population aged 2 to 5 years had a dental visit in the past year, suggesting that the mean age at first visit is more likely between 3 and 5 years. Access to dental care for young children enrolled in Medicaid is a particularly severe problem. Of children aged 1 to 5 years enrolled in the Early and Periodic Screening, Diagnostic, and Treatment Program (EPSDT), 16% receive any preventive dental care, even though all are eligible for these benefits.5 Reasons for this level of access include lack of parental awareness of recommended early visits, the reluctance of general dentists to treat young children, and a limited supply of dentists with specialty training in caring for young children.

Problems with access to dental care underscore the role that primary care physicians and other child healthcare providers can play in providing access to preventive dental services, particularly for very young children.3 Although the complete scope of opportunities for physician intervention for the prevention of dental diseases is much wider than simply the prevention of dental caries in preschool children, the rationale for focusing on preschool children and dental caries is compelling. Among young children who have experienced dental caries, a professional, preventive intervention presumably might have reduced or eliminated the incidence of disease and averted substantial interference with quality of life. Yet many children do not make a dental visit until well after the disease has progressed beyond the reversible stage. Children least likely to make an early dental visit are also those most likely to have dental caries.

Physicians and other primary care clinicians usually see children during this at-risk age before the first dental visit, providing an opportunity for them to take preventive action.10 Well-defined preventive procedures within the scope of medical practice are available for primary care clinicians to use in this preschool population. We reviewed the evidence for the effectiveness of primary care clinician–based interventions to prevent dental caries in preschool children.

Section snippets

Analytic framework and key questions

Figure 1 provides an analytic framework for this review. It represents a risk-based approach to the prevention and management of dental caries that begins with a child's visit to a primary care clinician, presumably a well-child visit. A primary care clinician screens the child for both the presence of dental caries and risk indicators for dental caries. On the basis of the results of the screening (either identification of suspected caries lesions or recognition of elevated risk for dental

Accuracy of screening

One hundred eighteen articles were identified, 12 reviewed in detail, and 2 included in this review of reports involving accuracy of the visual examination in identifying untreated decay requiring referral to a dentist (key question 1a).12, 13 Both compared the performance of single primary care clinician visual screeners, a nurse and a pediatrician, with that of a dentist after 5 and 4 hours of training, respectively. Sensitivities were 100% and 92%, and specificities were 87% and 99% for the

Strength of the evidence

The strength of the evidence addressing the first two key questions is poor. Two case studies found that single primary care clinicians identified caries lesions with an accuracy approaching that of dentists after 4 to 5 hours of training. The studies are consistent, but there are substantial questions about their external validity because each study involved only a single experimental subject. No evidence is available to document the accuracy with which primary care clinicians can identify

References (54)

  • W.E Mouradian et al.

    Disparities in children's oral health and access to dental care

    JAMA

    (2000)
  • U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville MD:...
  • Edelstein BL. The age one dental visit: information on the web. Pediatr Dent...
  • B.L Edelstein et al.

    Pediatric dental visits during 1996An analysis of the federal Medical Expenditure Panel Survey

    Pediatr Dent

    (2000)
  • General Accounting Office. Oral health: factors contributing to low use of dental services by low-income populations....
  • General Accounting Office. Oral health: dental disease is a chronic problem among low-income populations. Washington...
  • M.C McCormick et al.

    Annual report on access to and utilization of health care for children and youth in the United States–1999

    Pediatrics

    (2000)
  • A.I Ismail et al.

    Fluoride supplements and fluorosisA meta-analysis

    Community Dent Oral Epidemiol

    (1999)
  • J.R Serwint et al.

    Child-rearing practices and nursing caries

    Pediatrics

    (1993)
  • E.D Beltran et al.

    Validity of two methods for assessing oral health status of populations

    J Public Health Dent

    (1997)
  • M.D McCunniff et al.

    The impact of WIC dental screenings and referrals on utilization of dental services among low-income children

    Pediatr Dent

    (1998)
  • F.J Margolis et al.

    Fluoride supplements for children. A survey of physicians' prescription practices

    Am J Dis Child

    (1980)
  • C Siegel et al.

    Fluoride supplementation in Harris County, Texas

    Am J Dis Child

    (1982)
  • H.C Gift et al.

    Physicians and caries prevention. Results of a physician survey on preventive dental services

    JAMA

    (1984)
  • J.C Rigilano et al.

    Fluoride prescribing patterns among primary care physicians

    J Fam Pract

    (1985)
  • S.M Levy

    Systemic fluoride supplementation in an academic family practice setting

    J Fam Pract

    (1987)
  • R.A Kuthy et al.

    Fluoride prescription practices of Ohio physicians

    J Public Health Dent

    (1987)
  • Cited by (92)

    View all citing articles on Scopus

    Reprints are available from the AHRQ website (http://www.preventiveservices.ahrq.gov) and through the National Guideline Clearinghouse (http://www.guideline.gov). Print copies of this summary, along with other summaries and Recommendations and Rationale statements, are available by subscription to the Guide to Clinical Preventive Services, Third Edition: Periodic Updates. The cost of this subscription is $60 and available from the AHRQ Clearinghouse (call 1-800-358-9295 or e-mail [email protected]). Reprints of the USPSTF recommendations on this evidence revise can be found in Screening for Dementia: Recommendations and Rationale, available on the AHRQ website and in the Guide to Clinical Preventive Services, Third Edition: Periodic Updates). The first chapter appeared as an article in the American Journal of Preventive Medicine, supplement to volume 20, April 2001, pp. 1–108.

    View full text