Prevention of Dental Caries in Children From Birth Through Age 5 Years: US Preventive Services Task Force Recommendation Statement

1. Virginia A. Moyer, MD, MPH 
2. on behalf of the US Preventive Services Task Force
3. 1. DESCRIPTION: Update of the 2004 US Preventive Services Task Force (USPSTF) recommendation on prevention of dental caries in preschool-aged children.
      METHODS: The USPSTF reviewed the evidence on prevention of dental caries by primary care clinicians in children 5 years and younger, focusing on screening for caries, assessment of risk for future caries, and the effectiveness of various interventions that have possible benefits in preventing caries.
      POPULATION: This recommendation applies to children age 5 years and younger.
      RECOMMENDATION: The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I Statement)

Fluoride varnishes for preventing dental caries in children and adolescents

Marinho VCC, Worthington HV, Walsh T, Clarkson JE

 The Cochrane Library 13 MAY 2013 DOI: 10.1002/14651858.CD002279.pub2

Abstract

Background

Topically-applied fluoride varnishes have been used extensively as an operator-applied caries-preventive intervention for over three decades. This review updates the first Cochrane review of fluoride varnishes for preventing dental caries in children and adolescents, which was first published in 2002.

Objectives

To determine the effectiveness and safety of fluoride varnishes in preventing dental caries in children and adolescents, and to examine factors potentially modifying their effect.

Search methods

We searched the Cochrane Oral Health Group's Trials Register (to 13 May 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4), MEDLINE via OVID (1946 to 13 May 2013), EMBASE via OVID (1980 to 13 May 2013), CINAHL via EBSCO (1980 to 13 May 2013), LILACS and BBO via the BIREME Virtual Health Library (1980 to 13 May 2013), ProQuest Dissertations and Theses (1861 to 13 May 2013), and Web of Science Conference Proceedings (1945 to 13 May 2013). A search for ongoing trials was undertaken on ClinicalTrials.gov on 13 May 2013. There were no restrictions on language or date of publication in the search of the electronic databases.

Selection criteria

Randomised or quasi-randomised controlled trials with blind outcome assessment used or indicated, comparing topically-applied fluoride varnish with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent (D(M)FS) and primary (d(e/m)fs) teeth.

Data collection and analysis

At least two review authors assessed all search results, extracted data and undertook risk of bias independently. Study authors were contacted for additional information. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials.

Main results

Twenty-two trials with 12,455 participants randomised (9595 used in analyses) were included. For the 13 that contributed data for the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I² = 75%), however this body of evidence was assessed as of moderate quality. The pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001) for the 10 trials that contributed data for the primary tooth surfaces meta-analysis, also with some heterogeneity (P = 0.009; I² = 59%). Once again this body of evidence was assessed as of moderate quality. No significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the pre-specified factors of baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride, frequency of application were found. There was also no significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the post hoc factors: whether a placebo or no treatment control was used, length of follow-up, or whether individual or cluster randomisation was used, in the meta-regression models. A funnel plot of the trials in the main meta-analyses indicated no clear relationship between prevented fraction and study precision. In both methods, power is limited when few trials are included. There was little information concerning possible adverse effects or acceptability of treatment.

Authors' conclusions

The conclusions of this updated review remain the same as those when it was first published. The review suggests a substantial caries-inhibiting effect of fluoride varnish in both permanent and primary teeth, however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

 

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Plain language summary

Fluoride varnishes for preventing dental caries in children and adolescents

Review question

The main question addressed by this review is how effective the use of fluoride varnish for the prevention of caries in children and adolescents is compared to placebo (a treatment without the active ingredient i.e. fluoride) or no treatment.

Background

Tooth decay (dental caries) is a significant health problem worldwide. It affects not only the vast majority of adults but also children, from 60% to 90% of them. In other words, six to nine children in every 10 are affected by tooth decay. Levels of tooth decay vary both between and within different countries, but it is generally true that children in lower socio-economic groups (measured by income, education and employment) have greater levels of tooth decay. Untreated tooth decay causes progressive destruction of the tops of teeth (crowns) and this is often accompanied by severe pain and suffering. Repairing and replacing decayed teeth is extremely costly in terms of time and money and is a major drain on the resources of healthcare systems.

The prevention of dental caries in children and adolescents is regarded as a priority for dental services and considered more cost-effective than its treatment. Fluoride is a mineral that prevents tooth decay. Fluoride is added to the water supply in many areas. It can also be applied directly to teeth in the form of fluoride varnish. This is applied to first (baby) and permanent teeth (depending on the age of the child) usually by a dental professional from two to four times a year. Because it stays on the surface of the tooth for relatively long periods of time it releases fluoride in an efficient and effective way.

Study characteristics

This review of existing studies was carried out by the Cochrane Oral Health Group and the evidence is current up to 13 May 2013.
In this updated review there are now 22 trials published between 1975 and 2012 in which a total of 12,455 children were randomised to treatment with either fluoride varnish or placebo/no treatment. Study duration ranged from one to five years among included trials (12 of these lasted two years).

Key results

The evidence produced has been found to be of moderate quality due to issues with trial designs. However in the 13 trials that looked at children and adolescents with permanent teeth the review found that the young people treated with fluoride varnish experienced on average a 43% reduction in decayed, missing and filled tooth surfaces. In the 10 trials looking at the effect of fluoride varnish on first or baby teeth the evidence suggests a 37% reduction in decayed, missing and filled tooth surfaces. There was little information concerning possible adverse effects or acceptability of treatment.

Quality of the evidence

The evidence presented is of moderate quality due to issues with trial designs.

Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: a report of the American Dental Association Council on Scientific Affairs.

The Journal of the American Dental Association January 2011 vol. 142 no. 1 79-87

1. Joel Berg, DDS, 
2. Catherine Gerweck, DMD, MS, RD, 
3. Philippe P. Hujoel, MSD, PhD, 
4. Rebecca King, DDS, MPH, 
5. David M. Krol, MD, MPH,
6. Jayanth Kumar, DDS, MPH, 
7. Steven Levy, DDS, MPH, 
8. Howard Pollick, BDS, MPH, 
9. Gary M. Whitford, PhD, DMD, 
10. Sheila Strock, DMD, MPH,
11. Krishna Aravamudhan, BDS, MS, 
12. Julie Frantsve-Hawley, RDH, PhD,
13. Daniel M. Meyer, DDS and 
14. for the American Dental Association Council on Scientific Affairs Expert Panel on Fluoride Intake From Infant Formula and Fluorosis

Background. This article presents evidence-based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following question: Is consumption of infant formula reconstituted with water that contains various concentrations of fluoride by infants from birth to age 12 months associated with an increased risk of developing enamel fluorosis in the permanent dentition?

Types of Studies Reviewed. A panel of experts convened by the ADA CSA, in collaboration with staff of the ADA Center for Evidence-based Dentistry (CEBD), conducted a MEDLINE search to identify systematic reviews and clinical studies published since the systematic reviews were conducted that addressed the review question.

Results. CEBD staff identified one systematic review and two clinical studies. The panel reviewed this evidence to develop recommendations.

Clinical Implications. The panel suggested that when dentists advise parents and caregivers of infants who consume powdered or liquid concentrate infant formula as the main source of nutrition, they can suggest the continued use of powdered or liquid concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risks of enamel fluorosis development. These recommendations are presented as a resource to be considered in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.

Texto completo en PDF: http://jada.ada.org/content/142/1/79.full.pdf+html

Guideline on Xylitol Use in Caries Prevention

Council on Clinical Affairs. Guideline on xylitol use in caries prevention. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 4 p. [51 references]

Recommendations

Clinicians may consider recommending xylitol use to moderate or high caries risk patients. Those recommending xylitol should be familiar with the product labeling and recommend age-appropriate products. They should routinely reassess (not less than once every 6 months) a patient for changes in caries-risk status and adjust recommendations accordingly.

Dosage

There is accumulating evidence that total daily doses of 3 to 8 grams of xylitol are required for a clinical effect with the currently available delivery methods of syrup, chewing gum, and lozenges. Dosing frequency should be a minimum of 2 times a day, not to exceed 8 grams per day. Although tables of clinically effective xylitol containing products have recently been published, the products are continually changing.

Modality

Chewing gum has been the predominant modality for xylitol delivery in clinical studies. Studies that have utilized xylitol-containing mints and hard candies have shown them to be as effective as xylitol-containing chewing gum. The American Academy of Pediatrics (AAP) does not recommend use of chewing gum, mints, or hard candy by children less than 4 years of age due to the risk of choking. A randomized trial of xylitol syrup (8 g/day) reduced early childhood caries by 50 to 70 percent in children 15 to 25 months of age. Another study showed that gum or lozenges consumed by children at 5 grams total dose per day at about age 10 resulted in 35 to 60 percent reductions of tooth decay, with no differences between the delivery methods. Xylitol containing gummy bears, other confections, and even milk have been studied as delivery vehicles, but they are neither well established scientifically nor available commercially at present. A pacifier with a pouch containing slow release xylitol in tablet form, not yet available in the United States, has shown high salivary xylitol concentrations and may be a potential delivery vehicle for infants. Currently, xylitol-containing chewing gum, mints, energy bars and foods, nasal sprays, and oral hygiene products (e.g., mouth rinse, gels, wipes, floss) are commercially available through retail or online venues. However, they may not contain the necessary therapeutic level, xylitol as the only sweetener, or adequate labeling.

Studies using toothpaste formulations with 10% xylitol (dose of 0.1 g/brushing) have shown reduction in m

Guideline on Infant Oral Health Care

Clinical Affairs Committee - Infant Oral Health Subcommittee, Council on Clinical Affairs. Guideline on infant oral health care. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 5 p. [80 references]Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that infant oral health is one of the foundations upon which preventive education and dental care must be built to enhance the opportunity for a lifetime free from preventable oral disease. The AAPD proposes recommendations for preventive strategies, oral health risk assessment, anticipatory guidance, and therapeutic interventions to be followed by dental, 

medical, nursing, and allied health professional programs

Evidence-Based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention

A Report of the American Dental Association Council on Scientific Affairs

This article presents evidence-based clinical recommendations for the prescription of dietary fluoride supplements. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following questions: when and for whom should fluoride supplements be prescribed, and what should be the recommended dosage schedule for dietary fluoride supplements?

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Effectiveness of Preventive Dental Treatments by Physicians for Young Medicaid Enrollees

Pahel BT, Rozier RG, Stearns SC, Quiñonez RB
Pediatrics. 2011;127(3):e682-e689 (doi:10.1542/peds.2010-1457)

OBJECTIVE To estimate the effectiveness of a medical office–based preventive dental program (Into the Mouths of Babes [IMB]), which included fluoride varnish application, in reducing treatments related to dental caries.

METHODS We used longitudinal claims and enrollment data for all children aged 72 months or younger enrolled in North Carolina Medicaid from 2000 through 2006. Regression analyses compared subgroups of children who received up to 6 IMB visits at ages 6 to 35 months with children who received no IMB visits. Analyses were adjusted for child and area characteristics.

RESULTS Children enrolled in North Carolina Medicaid with 4 IMB visits experienced, on average, a 17% reduction in dental-caries–related treatments up to 6 years of age compared with children with no IMB visits. When we simulated data for initial IMB visits at 12 and 15 months of age, there was a cumulative 49% reduction in caries-related treatments at 17 months of age. The cumulative effectiveness declined because of an increase in treatments from 24 to 36 months, an increase in referrals for dental caries occurred with increasing time since fluoride application, and emergence of teeth not initially treated with fluoride.

CONCLUSIONS North Carolina's IMB program was effective in reducing caries-relatedtreatments for children with 4 IMB visits. Multiple applications of fluoride at the time of primary tooth emergence seem to be most beneficial. Referrals to dentists for treatment of existingdisease detected by physicians during IMB implementation limited the cumulative reductions in caries-related treatments, but also contributed to improved oral health.

Strategies to prevent dental caries in children and adolescents: evidence-based guidance on identifying high caries risk children and developing preve

Strategies to prevent dental caries in children and adolescents: evidence-based guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland.
Irish Oral Health Services Guideline Initiative. Strategies to prevent dental caries in children and adolescents: evidence-based guidance on identifying high caries risk children and developing preventive strategies for high caries risk children in Ireland. Cork (Ireland): Oral Health Services Research Centre; 2009. 90 p
Preventive Strategies

Oral health messages should be incorporated into relevant general health promotion interventions for children and adolescents as part of a common risk factor approach to improving oral health. [D]

Diet

Oral health education to parents/carers, children and adolescents should encourage healthy eating, in line with national dietary guidelines. [D]
Parents/carers should be encouraged to limit their child's consumption of sugar-containing foods and drinks, and when possible, to confine their consumption to mealtimes. [D]
Children and adolescents should be encouraged to limit their consumption of sugar-containing foods and drinks, and when possible, to confine their consumption to mealtimes. [D]
Parents and carers of children who use a baby bottle should be advised never to put sweet drinks, including fruit juice, into the bottle. [C]
Parents and carers should be advised not to let their child sleep or nap with a baby bottle or feeder cup. [GPP]
Parents/carers and children should be advised that foods and drinks containing sugar substitutes are available, but should be consumed in moderation. [D]
Sugar-free medicines should be used, when available. [D]
Topical Fluorides

Under 2 Years of Age: At Risk Children

Parents/carers should be encouraged to brush their child's teeth as soon as the first tooth appears, using a soft toothbrush and water only. [D]
Under 2 Years of Age: High Caries Risk Children

Parents/carers of children who are assessed as being at high caries risk should be encouraged to brush their child's teeth:
With fluoride toothpaste containing at least 1,000 parts per million fluoride (ppm F) [A]
Twice a day [B]
At bedtime and one other time during the day [GPP]
Using a small pea size amount of toothpaste [D]
Age 2 Years and Over
......

Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and a

Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents.

Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. Refer to the text of the original guideline document for supporting information and references.

Incluye tabla de actividades por grupos de edad

Guideline on perinatal oral health care.

Guideline on perinatal oral health care.
Every expectant mother receives a comprehensive oral health evaluation from a dentist and, if not previously accomplished, establishes a dental home as early as possible during pregnancy. The first visit should consist of review of medical, dental, and dietary histories, risk assessment for caries and periodontal disease, diagnosis of disease and other conditions, oral health education, and anticipatory guidance. Radiographic assessment and treatment of oral conditions should be performed with attention to maternal and fetal safety and patient comfort.
All primary health care professionals who serve pregnant women provide education on the etiology and prevention of early childhood caries (ECC). Oral health counseling and referral for a comprehensive oral examination and treatment during pregnancy is especially important for the mother.
The curriculum of all medical, nursing, and allied health professional programs include education in perinatal oral health, including the infectious etiology of ECC, methods of oral health risk assessment, anticipatory guidance, and the need for early establishment of a dental home.
Parents/caregivers establish a dental home for infants by 12 months of age.
Legislators, policy makers and third party payors be educated about the benefits of perinatal intervention in order to support efforts that improve access to oral health care for pregnant women, including more frequent and comprehensive services.

Guideline on infant oral health care.

Guideline on infant oral health care.All primary health care professionals who serve mothers and infants provide parent/caregiver education on the etiology and prevention of early childhood caries (ECC). Oral health counseling and referral for a comprehensive oral examination and treatment during pregnancy is especially important for the mother.
The infectious and transmissible nature of bacteria that cause ECC and methods of oral health risk assessment, anticipatory guidance, and early intervention be included in the curriculum of all medical, nursing, and allied health professional programs.
Every infant receive an oral health risk assessment from his/her primary health care provider or qualified health care professional by 6 months of age. This initial visit should consist of the following:
Assessing the patient's risk of developing oral disease using a caries risk assessment
Providing education on infant oral health
Evaluating and optimizing fluoride exposure
Parents or caregivers establish a dental home for infants by 12 months of age. The following should be accomplished at that visit:
Recording thorough medical (infant) and dental (mother or primary caregiver and infant) histories
Completing a thorough oral examination
Assessing the infant's risk of developing caries and determining an appropriate prevention plan and interval for periodic reevaluation based upon that assessment
Providing anticipatory guidance regarding dental and oral development, fluoride status, non-nutritive sucking habits, teething, injury prevention, oral hygiene instruction, and the effects of diet on the dentition
Planning for comprehensive care in accordance with accepted guidelines and periodicity schedules for pediatric oral health
Referring patients to the appropriate health professional if intervention is necessary

Guideline on fluoride therapy.

Guideline on fluoride therapy.

American Academy of Pediatric Dentistry Liaison with Other Groups Committee, American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on fluoride therapy. Pediatr Dent 2008-2009;30(7 Suppl):121-4.


MAJOR RECOMMENDATIONS
If an individual's caries risk level is uncertain, treating this person as high risk is prudent until further experience allows a more accurate assessment.
Systemically Administered Fluoride Supplements
Fluoride supplements should be considered for all children drinking fluoride-deficient (<0.6 parts per million [ppm]) water. After determining the fluoride level of the water supply or supplies (either through contacting public health officials or water analysis), evaluating other dietary sources of fluoride, and assessing the child's caries risk, the daily fluoride supplement dosage can be determined using the Dietary Fluoride Supplementation Schedule (see the table below). To optimize the topical benefits of systemic fluoride supplements, the child should be encouraged to chew or suck fluoride tablets.

Age	<0.3>	0.3-0.6 ppm F	>0.6 ppm F
Birth-6 months	0	0	0
6 months-3 years	0.25 mg	0	0
3-6 years	0.50 mg	0.25 mg	0
6 years up to at least 16 years	1.00 mg	0.50 mg	0

Professionally-Applied Topical Fluoride Treatment
Professional topical fluoride treatments should be based on caries-risk assessment. A pumice prophylaxis is not an essential prerequisite to this treatment. Appropriate precautionary measures should be taken to prevent swallowing of any professionally-applied topical fluoride. Children at moderate caries risk should receive a professional fluoride treatment at least every 6 months; those with high caries risk should receive greater frequency of professional fluoride applications (i.e., every 3-6 months). Ideally, this would occur as part of a comprehensive preventive program in a dental home. When a dental home cannot be established for individuals with increased caries risk as determined by caries risk assessment, periodic applications of fluoride varnish by trained non-dental healthcare professionals may be effective in reducing the incidence of early childhood caries.
Fluoride-Containing Products for Home Use
Therapeutic use of fluoride for children should focus on regimens that maximize topical contact, preferably in lower-dose, higher-frequency approaches. Fluoridated toothpaste should be used twice daily as a primary preventive procedure. Twice daily use has benefits greater than once daily brushing. Parents should be counseled on their child's caries risk, dispensing an appropriate volume of toothpaste onto a soft, age-appropriate sized toothbrush, frequency of brushing, and performing/assisting brushing of young children. A 'smear' of fluoridated toothpaste for children less than 2 years of age may decrease risk of fluorosis. A 'pea-size' amount of toothpaste is appropriate for children aged 2 through 5 years. To maximize the beneficial effect of fluoride in the toothpaste, rinsing after brushing should be kept to a minimum or eliminated altogether.
Additional at-home topical fluoride regimens utilizing increased concentrations of fluoride should be considered for children at high risk for caries. These may include over-the counter or prescription strength formulations. Fluoride mouth rinses or brush-on gels may be incorporated into a caries-prevention program for a school-aged child at high risk.