Prevention of dental caries in preschool children

American Family Physician,  Oct 15, 2004  

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This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on the primary care clinician's role in the prevention of dental disease among preschool-aged children based on the USPSTF's examination of evidence specific to dental disease in young children. It updates the 1996 recommendations contained in the Guide to Clinical Preventive Services, second edition. (1) Explanations of the ratings and strength of overall evidence are given in Tables 1 and 2, respectively. The complete information on which this statement is based, including evidence tables and references, is available in the summary article, "Physicians' roles in preventing dental caries in preschool children: a summary of the evidence for the U.S. Preventive Services Task Force," (2) and in the systematic evidence review, "Dental Caries Prevention: The Physician's Role in Child Oral Health." (3) The USPSTF recommendations, the accompanying summary article, and the complete systematic evidence review are available through the USPSTF Web site (www.preventiveservices.ahrq.gov). The summary article and the USPSTF recommendations and rationale statement are available in print through the AHRQ Publications Clearinghouse (telephone: 1-800-358-9295; e-mail: ahrqpubs@ahrq.gov). The recommendation also is posted on the Web site of the National Guideline Clearinghouse (http://www.guideline.gov).

This recommendation first appeared in Am J Prev Med 2004;26:326-9.

Summary of Recommendations

* The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended dosages to preschool-aged children older than six months of age whose primary water source is deficient in fluoride. B recommendation.

The USPSTF found fair evidence that, in preschool-aged children with low fluoride exposure, prescription of oral fluoride supplements by primary care physicians leads to reduced dental caries. The USPSTF concluded that the benefits of caries prevention using oral fluoride supplementation outweigh the potential harms of dental fluorosis, which in the United States are primarily observed as a mild cosmetic discoloration of the teeth.

The USPSTF concludes that the evidence is insufficient to recommend for or against routine risk assessment of preschool-aged children by primary care physicians for the prevention of dental disease. I recommendation.

* The USPSTF found no validated risk-assessment tools or algorithms for assessing dental disease risk by primary care physicians and little evidence that primary care physicians are able to systematically assess risk for dental disease among preschool-aged children. The USPSTF further found little evidence that either counseling of parents or referring high-risk children to dental care providers results in fewer caries or reduced dental disease. Thus, the USPSTF concluded there is insufficient evidence to determine the balance between the benefits and harms of routine risk assessment to prevent dental disease among preschool children.

Clinical Considerations

* Dental disease is prevalent among young children, particularly those from lower socioeconomic populations; however, few preschool-aged children ever visit a dentist. Primary care physicians are often the first and only health professionals whom children visit. Therefore, they are in a unique position to address dental disease in these children.

* Fluoride varnishes, professionally applied topical fluorides approved to prevent dental caries in young children, are adjuncts to oral supplementation. Their advantages over other topical fluoride agents (i.e., mouth rinse and gel) include ease of use, patient acceptance, and reduced potential for toxicity.

* Dental fluorosis (rather than skeletal fluorosis) is the most common harm of either oral fluoride or fluoride toothpaste use in children younger than two years in the United States. Dental fluorosis is typically very mild and only of aesthetic importance. The recommended dosage of fluoride supplementation was reduced by the American Dental Association in 1994, which is likely to decrease the prevalence and severity of dental fluorosis. The current dosage recommendations are based on the fluoride level of the local community's water supply and are available online at http://www.ada.org. The primary care physician's knowledge of the fluoride level of his or her patients' primary water supply ensures appropriate fluoride supplementation and minimizes risk for fluorosis.

Discussion

Dental caries is a common childhood disease: as many as 19 percent of children aged two to five years and 52 percent of children aged five to nine years have experienced dental caries. (4,5) Minority and economically disadvantaged children have a higher prevalence and severity of caries compared with other groups. (3) Untreated caries in primary teeth may lead to caries in permanent teeth and a possible loss of arch space. (3)

Although a first dental visit is recommended when a child is approximately one year old, (6) only 36 percent of two- to four-year-olds have had a dental visit in the past year; thus, primary care physicians have a role in providing access to preventive dental services, particularly for very young and disadvantaged children. (5) The USPSTF reviewed the evidence for the prevention and management of dental caries in children up to five years of age. The review did not cover the evidence for water fluoridation, application of dental sealants, or prenatal counseling. However, based on strong evidence, the Centers for Disease Control and Prevention Task Force on Community Preventive Services has recommended that local water fluoridation be a part of a population-based strategy for the prevention of tooth decay in communities. The recommendation can be accessed at http://www.thecommunityguide.org/oral/.