Review and special articlePhysicians' roles in preventing dental caries in preschool children: A summary of the evidence for the U.S. Preventive Services Task Force☆
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)
- et al.
Sociodemographic distribution of pediatric dental cariesNHANES III, 1988–1994
J Am Dent Assoc
(1998) Controlled trial of fluoride in vitamin drops for prevention of caries in children
Lancet
(1971)- et al.
Prophylaxis of dental cariesRelative effectiveness of chewable fluoride preparations with and without added vitamins
J Pediatr
(1972) - et al.
Fluoride-vitamin supplementsEffects on dental caries and fluorosis when used in areas with suboptimum fluoride in the water supply
J Am Dent Assoc
(1977) - et al.
Prevalence and trends in enamel fluorosis in the United States from the 1930s to the 1980s
J Am Dent Assoc
(2002) Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populationsConsiderations for the dental professional
J Am Dent Assoc
(2000)- et al.
Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition
J Am Dent Assoc
(2001) - et al.
Fluoride varnishes. A review of their clinical use, cariostatic mechanism, efficacy and safety
J Am Dent Assoc
(2000) Evidence-based dental care for children and the age 1 dental visit
Pediatr Ann
(1998)- et al.
The unmet health needs of America's children
Pediatrics
(2000)
Disparities in children's oral health and access to dental care
JAMA
Pediatric dental visits during 1996An analysis of the federal Medical Expenditure Panel Survey
Pediatr Dent
Annual report on access to and utilization of health care for children and youth in the United States–1999
Pediatrics
Fluoride supplements and fluorosisA meta-analysis
Community Dent Oral Epidemiol
Child-rearing practices and nursing caries
Pediatrics
Validity of two methods for assessing oral health status of populations
J Public Health Dent
The impact of WIC dental screenings and referrals on utilization of dental services among low-income children
Pediatr Dent
Fluoride supplements for children. A survey of physicians' prescription practices
Am J Dis Child
Fluoride supplementation in Harris County, Texas
Am J Dis Child
Physicians and caries prevention. Results of a physician survey on preventive dental services
JAMA
Fluoride prescribing patterns among primary care physicians
J Fam Pract
Systemic fluoride supplementation in an academic family practice setting
J Fam Pract
Fluoride prescription practices of Ohio physicians
J Public Health Dent
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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.