Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force | Guidelines | JAMA | JAMA Network
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Figure 1.  Analytic Framework: Screening for Dental Caries in Children Younger Than 5 Years
Analytic Framework: Screening for Dental Caries in Children Younger Than 5 Years

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line indicates a health outcome that immediately follows an intermediate outcome. For additional information see the USPSTF Procedure Manual.10

aInterventions are provided to children found to have caries on screening.

Figure 2.  Analytic Framework: Interventions to Prevent Dental Caries in Children Younger Than 5 Years
Analytic Framework: Interventions to Prevent Dental Caries in Children Younger Than 5 Years

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. For additional information see the USPSTF Procedure Manual.10

aInterventions are provided to children without caries.

bThis is the same question as screening key question 2b.

Figure 3.  Literature Search Flow Diagram: Screening for Dental Caries in Children Younger Than 5 Years
Literature Search Flow Diagram: Screening for Dental Caries in Children Younger Than 5 Years

KQ indicates key question.

aIdentified from reference lists, hand searching, suggested by experts, etc.

bStudies that provided data and contributed to the body of evidence were considered included.

cStudies may have contributed data for more than 1 KQ.

Figure 4.  Pooled Analysis of Topical Fluoride vs Placebo or No Topical Fluoride on Mean Change in Number of Caries at Follow-up, by Fluoridation Status
Pooled Analysis of Topical Fluoride vs Placebo or No Topical Fluoride on Mean Change in Number of Caries at Follow-up, by Fluoridation Status

The size of the data markers indicates the weight of each study in the analysis. dmfs indicates decayed, missing, or filled surfaces; dmft, decayed, missing, or filled teeth.

aSubscripts indicate the extent of the caries lesion (eg, d1 indicates noncavitated enamel lesion; d2, cavitated enamel lesion; d3, dentin lesion; d4, lesion extending into pulp).

bStudy adjusted for clustering design or other confounding variables.

Figure 5.  Pooled Analysis of Topical Fluoride vs Placebo or No Topical Fluoride on Caries Development at Follow-up, by Fluoridation Status
Pooled Analysis of Topical Fluoride vs Placebo or No Topical Fluoride on Caries Development at Follow-up, by Fluoridation Status

The size of the data markers indicates the weight of each study in the analysis. dmfs indicates decayed, missing, or filled surfaces; dmft, decayed, missing, or filled teeth; ICDAS, International Caries Detection and Assessment System.

aSubscripts indicate the extent of the caries lesion (eg, d1 indicates noncavitated enamel lesion; d2, cavitated enamel lesion; d3, dentin lesion; d4, lesion extending into pulp).

bStudy adjusted for clustering design or other confounding variables.

Table 1.  Pooled Analyses of Mean Change in Number of Caries at Follow-up, Topical Fluoride vs Placebo or No Topical Fluoride
Pooled Analyses of Mean Change in Number of Caries at Follow-up, Topical Fluoride vs Placebo or No Topical Fluoride
Table 2.  Pooled Analyses of Risk of Caries Development at Follow-up, Topical Fluoride vs Placebo or No Topical Fluoride
Pooled Analyses of Risk of Caries Development at Follow-up, Topical Fluoride vs Placebo or No Topical Fluoride
Table 3.  Summary of Evidence
Summary of Evidence
1.
 Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999-2004 to 2011-2016. Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2019.
2.
Dye  BA, Mitnik  GL, Iafolla  TJ, Vargas  CM.  Trends in dental caries in children and adolescents according to poverty status in the United States from 1999 through 2004 and from 2011 through 2014.   J Am Dent Assoc. 2017;148(8):550-565. doi:10.1016/j.adaj.2017.04.013PubMedGoogle ScholarCrossref
3.
Dooley  D, Moultrie  NM, Heckman  B, Gansky  SA, Potter  MB, Walsh  MM.  Oral health prevention and toddler well-child care: routine integration in a safety net system.   Pediatrics. 2016;137(1):e20143532. doi:10.1542/peds.2014-3532PubMedGoogle Scholar
4.
Institute of Medicine; National Research Council.  Improving Access to Oral Health Care for Vulnerable and Underserved Populations. National Academies Press; 2011.
5.
Nicolae  A, Levin  L, Wong  PD,  et al.  Identification of early childhood caries in primary care settings.   Paediatr Child Health. 2018;23(2):111-115. doi:10.1093/pch/pxx155PubMedGoogle ScholarCrossref
6.
Moyer  VA; US Preventive Services Task Force.  Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.   Pediatrics. 2014;133(6):1102-1111. doi:10.1542/peds.2014-0483PubMedGoogle ScholarCrossref
7.
Chou  R, Cantor  A, Zakher  B, Mitchell  JP, Pappas  M.  Preventing dental caries in children <5 years: systematic review updating USPSTF recommendation.   Pediatrics. 2013;132(2):332-350. doi:10.1542/peds.2013-1469PubMedGoogle ScholarCrossref
8.
Chou  R, Cantor  A, Zakher  B,  et al.  Prevention of Dental Caries in Children Younger Than 5 Years Old: Systematic Review to Update the US Preventive Services Task Force Recommendation. Evidence Synthesis No. 104. Agency for Healthcare Research and Quality; 2014. AHRQ publication 12-05170-EF-1.
9.
Chou  R, Pappas  M, Dana  T, Selph  S, Hart  E, Schwarz  E.  Screening and Prevention of Dental Caries in Children Younger Than Five Years of Age: A Systematic Review for the US Preventive Services Task Force. Evidence Synthesis No. 210. Agency for Healthcare Research and Quality; 2021. AHRQ publication 21-05279-EF-1.
10.
Procedure Manual. US Preventive Services Task Force. Published May 2021. Accessed August 31, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
11.
Higgins  JP, Thompson  SG.  Quantifying heterogeneity in a meta-analysis.   Stat Med. 2002;21(11):1539-1558. doi:10.1002/sim.1186PubMedGoogle ScholarCrossref
12.
Human Development Report 2020: Reader's Guide. United Nations Development Programme. Accessed August 6, 2021. http://hdr.undp.org/en/content/human-development-report-2020-readers-guide
13.
Pierce  KM, Rozier  RG, Vann  WF  Jr.  Accuracy of pediatric primary care providers’ screening and referral for early childhood caries.   Pediatrics. 2002;109(5):E82-E2. doi:10.1542/peds.109.5.e82PubMedGoogle ScholarCrossref
14.
Serwint  JR, Mungo  R, Negrete  VF, Duggan  AK, Korsch  BM.  Child-rearing practices and nursing caries.   Pediatrics. 1993;92(2):233-237.PubMedGoogle Scholar
15.
MacRitchie  HM, Longbottom  C, Robertson  M,  et al.  Development of the Dundee Caries Risk Assessment Model (DCRAM)—risk model development using a novel application of CHAID analysis.   Community Dent Oral Epidemiol. 2012;40(1):37-45. doi:10.1111/j.1600-0528.2011.00630.xPubMedGoogle ScholarCrossref
16.
Basir  L, Rasteh  B, Montazeri  A, Araban  M.  Four-level evaluation of health promotion intervention for preventing early childhood caries: a randomized controlled trial.   BMC Public Health. 2017;17(1):767. doi:10.1186/s12889-017-4783-9PubMedGoogle ScholarCrossref
17.
Beil  H, Rozier  RG, Preisser  JS, Stearns  SC, Lee  JY.  Effect of early preventive dental visits on subsequent dental treatment and expenditures.   Med Care. 2012;50(9):749-756. doi:10.1097/MLR.0b013e3182551713PubMedGoogle ScholarCrossref
18.
Beil  H, Rozier  RG, Preisser  JS, Stearns  SC, Lee  JY.  Effects of early dental office visits on dental caries experience.   Am J Public Health. 2014;104(10):1979-1985. doi:10.2105/AJPH.2013.301325PubMedGoogle ScholarCrossref
19.
Blackburn  J, Morrisey  MA, Sen  B.  Outcomes associated with early preventive dental care among Medicaid-enrolled children in Alabama.   JAMA Pediatr. 2017;171(4):335-341. doi:10.1001/jamapediatrics.2016.4514PubMedGoogle ScholarCrossref
20.
Kranz  AM, Rozier  RG, Preisser  JS, Stearns  SC, Weinberger  M, Lee  JY.  Preventive services by medical and dental providers and treatment outcomes.   J Dent Res. 2014;93(7):633-638. doi:10.1177/0022034514536731PubMedGoogle ScholarCrossref
21.
Kranz  AM, Rozier  RG, Preisser  JS, Stearns  SC, Weinberger  M, Lee  JY.  Comparing medical and dental providers of oral health services on early dental caries experience.   Am J Public Health. 2014;104(7):e92-e99. doi:10.2105/AJPH.2014.301972PubMedGoogle ScholarCrossref
22.
Sen  B, Blackburn  J, Kilgore  ML,  et al.  Preventive dental care and long-term dental outcomes among ALL Kids enrollees.   Health Serv Res. 2016;51(6):2242-2257. doi:10.1111/1475-6773.12469PubMedGoogle ScholarCrossref
23.
Lin  YT, Tsai  CL.  Comparative anti-caries effects of tablet and liquid fluorides in cleft children.   J Clin Dent. 2000;11(4):104-106. PubMedGoogle Scholar
24.
Hamberg  L.  Controlled trial of fluoride in vitamin drops for prevention of caries in children.   Lancet. 1971;1(7696):441-442. doi:10.1016/S0140-6736(71)92426-3PubMedGoogle ScholarCrossref
25.
Hennon  DK, Stookey  GK, Muhler  JC.  Prophylaxis of dental caries: relative effectiveness of chewable fluoride preparations with and without added vitamins.   J Pediatr. 1972;80(6):1018-1021. doi:10.1016/S0022-3476(72)80016-7PubMedGoogle ScholarCrossref
26.
Hu  D, Wan  H, Li  S.  The caries-inhibiting effect of a fluoride drop program: a 3-year study on Chinese kindergarten children.   Chin J Dent Res. 1998;1(3):17-20.PubMedGoogle Scholar
27.
Margolis  FJ, Macauley  J, Freshman  E.  The effects of measured doses of fluoride: a five-year preliminary report.   Am J Dis Child. 1967;113(6):670-672. doi:10.1001/archpedi.1967.02090210084007PubMedGoogle ScholarCrossref
28.
Margolis  FJ, Reames  HR, Freshman  E, MaCauley  CD, Mehaffey  H.  Flouride: ten-year prospective study of deciduous and permanent dentition.   Am J Dis Child. 1975;129(7):794-800. doi:10.1001/archpedi.1975.02120440020006PubMedGoogle ScholarCrossref
29.
Frostell  G, Birkhed  D, Edwardsson  S,  et al.  Effect of partial substitution of invert sugar for sucrose in combination with Duraphat treatment on caries development in preschool children: the Malmö Study.   Caries Res. 1991;25(4):304-310. doi:10.1159/000261381PubMedGoogle ScholarCrossref
30.
Jiang  H, Bian  Z, Tai  BJ, Du  MQ, Peng  B.  The effect of a bi-annual professional application of APF foam on dental caries increment in primary teeth: 24-month clinical trial.   J Dent Res. 2005;84(3):265-268. doi:10.1177/154405910508400311PubMedGoogle ScholarCrossref
31.
Lawrence  HP, Binguis  D, Douglas  J,  et al.  A 2-year community-randomized controlled trial of fluoride varnish to prevent early childhood caries in Aboriginal children.   Community Dent Oral Epidemiol. 2008;36(6):503-516. doi:10.1111/j.1600-0528.2008.00427.xPubMedGoogle ScholarCrossref
32.
Slade  GD, Bailie  RS, Roberts-Thomson  K,  et al.  Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial.   Community Dent Oral Epidemiol. 2011;39(1):29-43. doi:10.1111/j.1600-0528.2010.00561.xPubMedGoogle ScholarCrossref
33.
Weintraub  JA, Ramos-Gomez  F, Jue  B,  et al.  Fluoride varnish efficacy in preventing early childhood caries.   J Dent Res. 2006;85(2):172-176. doi:10.1177/154405910608500211PubMedGoogle ScholarCrossref
34.
Agouropoulos  A, Twetman  S, Pandis  N, Kavvadia  K, Papagiannoulis  L.  Caries-preventive effectiveness of fluoride varnish as adjunct to oral health promotion and supervised tooth brushing in preschool children: a double-blind randomized controlled trial.   J Dent. 2014;42(10):1277-1283. doi:10.1016/j.jdent.2014.07.020PubMedGoogle ScholarCrossref
35.
Anderson  M, Dahllöf  G, Soares  FC, Grindefjord  M.  Impact of biannual treatment with fluoride varnish on tooth-surface–level caries progression in children aged 1-3 years.   J Dent. 2017;65:83-88. doi:10.1016/j.jdent.2017.07.009PubMedGoogle ScholarCrossref
36.
Anderson  M, Dahllöf  G, Twetman  S, Jansson  L, Bergenlid  AC, Grindefjord  M.  Effectiveness of early preventive intervention with semiannual fluoride varnish application in toddlers living in high-risk areas: a stratified cluster-randomized controlled trial.   Caries Res. 2016;50(1):17-23. doi:10.1159/000442675PubMedGoogle ScholarCrossref
37.
Jiang  EM, Lo  EC, Chu  CH, Wong  MC.  Prevention of early childhood caries (ECC) through parental toothbrushing training and fluoride varnish application: a 24-month randomized controlled trial.   J Dent. 2014;42(12):1543-1550. doi:10.1016/j.jdent.2014.10.002PubMedGoogle ScholarCrossref
38.
Latifi-Xhemajli  B, Begzati  A, Veronneau  J, Kutllovci  T, Rexhepi  A.  Effectiveness of fluoride varnish four times a year in preventing caries in the primary dentition: a 2 year randomized controlled trial.   Community Dent Health. 2019;36(2):190-194. doi:10.1922/CDH_4453Begzati05PubMedGoogle Scholar
39.
McMahon  AD, Wright  W, Anopa  Y,  et al.  Fluoride varnish in nursery schools: a randomised controlled trial—Protecting Teeth @3.   Caries Res. 2020;54(3):274-282. doi:10.1159/000509680PubMedGoogle ScholarCrossref
40.
Memarpour  M, Dadaein  S, Fakhraei  E, Vossoughi  M.  Comparison of oral health education and fluoride varnish to prevent early childhood caries: a randomized clinical trial.   Caries Res. 2016;50(5):433-442. doi:10.1159/000446877PubMedGoogle ScholarCrossref
41.
Memarpour  M, Fakhraei  E, Dadaein  S, Vossoughi  M.  Efficacy of fluoride varnish and casein phosphopeptide-amorphous calcium phosphate for remineralization of primary teeth: a randomized clinical trial.   Med Princ Pract. 2015;24(3):231-237. doi:10.1159/000379750PubMedGoogle ScholarCrossref
42.
Muñoz-Millán  P, Zaror  C, Espinoza-Espinoza  G,  et al.  Effectiveness of fluoride varnish in preventing early childhood caries in rural areas without access to fluoridated drinking water: a randomized control trial.   Community Dent Oral Epidemiol. 2018;46(1):63-69. doi:10.1111/cdoe.12330PubMedGoogle ScholarCrossref
43.
Oliveira  BH, Salazar  M, Carvalho  DM, Falcão  A, Campos  K, Nadanovsky  P.  Biannual fluoride varnish applications and caries incidence in preschoolers: a 24-month follow-up randomized placebo-controlled clinical trial.   Caries Res. 2014;48(3):228-236. doi:10.1159/000356863PubMedGoogle ScholarCrossref
44.
Tickle  M, O'Neill  C, Donaldson  M,  et al.  A randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services: the Northern Ireland Caries Prevention In Practice (NIC-PIP) trial.   Health Technol Assess. 2016;20(71):1-96. doi:10.3310/hta20710PubMedGoogle ScholarCrossref
45.
Tickle  M, O’Neill  C, Donaldson  M,  et al.  A randomized controlled trial of caries prevention in dental practice.   J Dent Res. 2017;96(7):741-746. doi:10.1177/0022034517702330PubMedGoogle ScholarCrossref
46.
Zhan  L, Cheng  J, Chang  P,  et al.  Effects of xylitol wipes on cariogenic bacteria and caries in young children.   J Dent Res. 2012;91(7)(suppl):85S-90S. doi:10.1177/0022034511434354PubMedGoogle Scholar
47.
Oscarson  P, Lif Holgerson  P, Sjöström  I, Twetman  S, Stecksén-Blicks  C.  Influence of a low xylitol-dose on mutans streptococci colonisation and caries development in preschool children.   Eur Arch Paediatr Dent. 2006;7(3):142-147. doi:10.1007/BF03262555PubMedGoogle ScholarCrossref
48.
Dos Santos  AP, Malta  MC, de Marsillac  MW, de Oliveira  BH.  Fluoride varnish applications in preschoolers and dental fluorosis in permanent incisors: results of a nested-cohort study within a clinical trial.   Pediatr Dent. 2016;38(5):414-418.PubMedGoogle Scholar
49.
Ismail  AI, Hasson  H.  Fluoride supplements, dental caries and fluorosis: a systematic review.   J Am Dent Assoc. 2008;139(11):1457-1468. doi:10.14219/jada.archive.2008.0071PubMedGoogle ScholarCrossref
50.
Bader  JD, Rozier  G, Harris  R,  et al.  Dental Caries Prevention: The Physician's Role in Child Oral Health Systematic Evidence Review. Agency for Healthcare Research and Quality; 2004.
51.
Harris  R, Nicoll  AD, Adair  PM, Pine  CM.  Risk factors for dental caries in young children: a systematic review of the literature.   Community Dent Health. 2004;21(1)(suppl):71-85.PubMedGoogle Scholar
52.
Holgerson  PL, Twetman  S, Stecksèn-Blicks  C.  Validation of an age-modified caries risk assessment program (Cariogram) in preschool children.   Acta Odontol Scand. 2009;67(2):106-112. doi:10.1080/00016350802714734PubMedGoogle ScholarCrossref
53.
Bader  JD, Rozier  RG, Lohr  KN, Frame  PS.  Physicians’ roles in preventing dental caries in preschool children: a summary of the evidence for the US Preventive Services Task Force.   Am J Prev Med. 2004;26(4):315-325. doi:10.1016/j.amepre.2003.12.001PubMedGoogle ScholarCrossref
54.
Wiener  RC, Shen  C, Findley  P, Tan  X, Sambamoorthi  U.  Dental fluorosis over time: a comparison of National Health and Nutrition Examination Survey data from 2001-2002 and 2011-2012.   J Dent Hyg. 2018;92(1):23-29.PubMedGoogle Scholar
55.
Autio-Gold  J.  Recommendations for fluoride varnish use in caries management.   Dent Today. 2008;27(1):64-67.PubMedGoogle Scholar
56.
Bawden  JW.  Fluoride varnish: a useful new tool for public health dentistry.   J Public Health Dent. 1998;58(4):266-269. doi:10.1111/j.1752-7325.1998.tb03007.xPubMedGoogle ScholarCrossref
57.
Ruff  RR, Niederman  R.  Silver diamine fluoride versus therapeutic sealants for the arrest and prevention of dental caries in low-income minority children: study protocol for a cluster randomized controlled trial.   Trials. 2018;19(1):523. doi:10.1186/s13063-018-2891-1PubMedGoogle ScholarCrossref
58.
Ruff  RR, Niederman  R.  Comparative effectiveness of school-based caries prevention: a prospective cohort study.   BMC Oral Health. 2018;18(1):53. doi:10.1186/s12903-018-0514-6PubMedGoogle ScholarCrossref
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    US Preventive Services Task Force
    Evidence Report
    December 7, 2021

    Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

    Author Affiliations
    • 1Department of Medical Informatics and Clinical Epidemiology, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
    • 2Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
    • 3School of Public Health, Oregon Health & Science University–Portland State University, Portland
    • 4School of Dentistry, Oregon Health & Science University, Portland
    JAMA. 2021;326(21):2179-2192. doi:10.1001/jama.2021.15658
    Abstract

    Importance  A 2014 review for the US Preventive Services Task Force (USPSTF) found that oral fluoride supplementation and topical fluoride use were associated with reduced caries incidence in children younger than 5 years.

    Objective  To update the 2014 review on dental caries screening and preventive interventions to inform the USPSTF.

    Data Sources  Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to September 2020); surveillance through July 23, 2021.

    Study Selection  Randomized clinical trials (RCTs) on screening, preventive interventions, referral to dental care; cohort studies on screening and referral; studies on diagnostic accuracy of primary care oral examination or risk assessment; and a systematic review on risk of fluorosis included in prior USPSTF reviews.

    Data Extraction and Synthesis  One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality.

    Results  Thirty-two studies (19 trials, 9 observational studies, and 4 nonrandomized clinical intervention studies [total 106 694 participants] and 1 systematic review [19 studies]) were included. No study evaluated effects of primary care screening on clinical outcomes. One study (n = 258) found primary care pediatrician examination associated with a sensitivity of 0.76 (95% CI, 0.55 to 0.91) and specificity of 0.95 (95% CI, 0.92 to 0.98) for identifying a child with cavities, and 1 study found a risk assessment tool associated with sensitivity of 0.53 and specificity of 0.77 (n = 697, CIs not reported) for a child with future caries. No new trials of dietary fluoride supplementation were identified. For prevention, topical fluoride compared with placebo or no topical fluoride was associated with decreased caries burden (13 trials, n = 5733; mean caries increment [difference in decayed, missing, and filled teeth or surfaces], −0.94 [95% CI, −1.74 to −0.34]) and likelihood of incident caries (12 trials, n = 8177; RR, 0.80 [95% CI, 0.66 to 0.95]; absolute risk difference, −7%) in higher-risk populations or settings, with no increased fluorosis risk. Evidence on other preventive interventions was limited (education, xylitol) or unavailable (silver diamine fluoride), and no study directly evaluated primary care dentistry referral vs no referral.

    Conclusions and Relevance  There was no direct evidence on benefits and harms of primary care oral health screening or referral to dentist. Dietary fluoride supplementation and fluoride varnish were associated with improved caries outcomes in higher-risk children and settings.

    Introduction

    Dental caries is a common chronic disease that can cause pain and diminish function and quality of life.1 Dental caries is the most common chronic disease of children in the US and disproportionately affects vulnerable and underserved children.1,2 Children who lack access to a dentist often have encounters with a primary care clinician. Therefore, provision of oral care in primary care settings may improve access and facilitate provision of treatments to prevent or treat caries and improve outcomes.3-5

    In 2014, the US Preventive Services Task Force (USPSTF) recommended that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride and apply fluoride varnish starting at the age of primary tooth eruption for all children (B recommendations).6 The USPSTF found insufficient evidence to assess the benefits and harms of dental caries screening by primary care clinicians in children younger than 5 years (I statement). This evidence report was conducted to update the 2014 USPSTF review on dental caries screening and preventive interventions in children younger than 5 years,7,8 to inform the USPSTF for an updated recommendation statement.

    Methods
    Scope of Review

    Detailed methods and study details are available in the full evidence report.9 Figure 1 (screening) and Figure 2 (preventive interventions) show the analytic frameworks and key questions (KQs) that guided the review. Separate analytic frameworks were used to distinguish treatment of children with existing caries (screening) from treatment of children without caries (preventive interventions).

    Data Sources and Searches

    Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were searched from 2013 through September 2020 (see the Supplement for search strategies). Searches were supplemented by reference list review of relevant systematic reviews; studies from the prior USPSTF review7,8 that met inclusion criteria were carried forward. Ongoing surveillance was conducted to identify major studies published since September 2020 that may affect the conclusions or understanding of the evidence and the related USPSTF recommendation. The last surveillance was conducted on July 23, 2021, and identified no studies affecting review conclusions.

    Study Selection

    Two investigators independently reviewed titles, abstracts, and full-text articles using predefined eligibility criteria. The population was children younger than 5 years. Screening and diagnostic accuracy studies conducted in primary care settings were eligible. Eligible preventive interventions were primary care feasible (not requiring extensive dental training): parental or caregiver education, referral to a dentist, dietary fluoride supplementation, topical fluoride application (varnish, foam, or gel), xylitol, and silver diamine fluoride. Comparisons were against placebo or no intervention. Outcomes were dental caries (incidence or caries burden, measured based on the number of decayed, missing, or filled teeth [dmft] or decayed, missing, or filled surfaces), morbidity, quality of life, and harms (including fluorosis).

    Data Extraction and Quality Assessment

    One investigator abstracted details about the study design, patient population, setting, interventions, analysis, follow-up, and results from each study. A second investigator reviewed abstracted data for accuracy. Two independent investigators assessed the quality of each study as good, fair, or poor using predefined criteria developed by the USPSTF (see the Supplement for quality rating criteria).10 Discrepancies were resolved through consensus. In accordance with the USPSTF Procedure Manual,10 studies rated poor quality owing to critical methodological limitations were excluded.

    Data Synthesis and Analysis

    For all KQs, the overall quality of evidence was rated “good,” “fair,” or “poor” based on study limitations, consistency, precision, reporting bias, and applicability, using the approach described in the USPSTF Procedure Manual.10

    Meta-analysis was conducted only for topical fluoride, because of small numbers of trials of other preventive interventions with clinical and methodological heterogeneity. For topical fluoride, random-effects meta-analysis was performed to summarize the likelihood of incident caries or caries increment (difference in mean caries burden) vs placebo or no topical fluoride using a profile likelihood model in Stata/SE 16.1 (StataCorp). Statistical heterogeneity was assessed using the I2 statistic.11 Analyses were stratified by community fluoridation status (adequate [≥0.7 parts fluoride per million parts water {ppm F} vs nonadequate) and topical fluoride type (varnish vs foam or gel). Additional subgroup analyses were conducted on use of cluster randomization, follow-up duration, varnish frequency, use of additional oral health measures, very high Human Development Index (HDI) setting (based on a United Nations Development Programme HDI score of 0.800 or higher for the country or geographic setting),12 conducted in preschool or daycare setting, conducted in high-risk population, and inclusion of children with caries at baseline. A random-effects meta-regression model was used to test subgroup differences. All significance testing was 2-tailed; P values of .05 or less were considered statistically significant.

    Results

    Across all KQs, 32 studies (reported in 35 publications, total 106 694 participants)13-48 and 1 systematic review (19 studies)49 were included (Figure 3). Seventeen studies15,16,18-22,34-45,48 were new for this update and 16 studies (including the systematic review)13,14,17,23-33,46,47,49 were carried forward from the previous USPSTF review.

    Screening
    Benefits of Screening

    Key Question 1. How effective is oral screening (including risk assessment) performed by a primary care clinician in preventing dental caries in children younger than 5 years?

    No study met inclusion criteria for this KQ.

    Accuracy of Screening

    Key Question 2a. How accurate is screening performed by a primary care clinician in identifying children younger than 5 years who have cavitated or noncavitated caries lesions?

    No new study met inclusion criteria for this KQ. Two studies in the prior USPSTF review compared a pediatrician vs pediatric dentist oral examination (eTables 1 and 2 in the Supplement). One good-quality study of children younger than 36 months (n = 258) reported a sensitivity of 0.76 (95% CI, 0.55 to 0.91) and specificity of 0.95 (95% CI, 0.92 to 0.98) for identifying a child with 1 or more cavities and a sensitivity of 0.49 (95% CI, 0.37 to 0.60) and specificity of 0.99 (95% CI, 0.99 to 0.99) for identifying a tooth with a cavity.13 A fair-quality study of children aged 18 to 36 months reported a sensitivity of 1.0 and specificity of 0.87 for identifying nursing caries (n = 61, CIs not reported).14

    Key Question 2b. How accurate is screening performed by a primary care clinician in identifying children younger than 5 years who are at increased risk for future dental caries?

    One new fair-quality study (n = 1681) found a caries risk assessment tool administered by health visitor nurses in children aged 1 year associated with sensitivity of 0.53 and specificity of 0.77 (n = 697, CIs not reported) for predicting any d3mft lesion (d3 indicates dentin caries lesion) at age 4 years and sensitivity of 0.65 and specificity of 0.69 (n = 784, CIs not reported) for predicting presence of 3 or more d3mft lesions (eTables 2 and 3 in the Supplement).15

    Harms of Screening

    Key Question 3. What are the harms of oral health screening performed by a primary care clinician in children younger than 5 years?

    No study met inclusion criteria for this KQ.

    Preventive Interventions
    Accuracy of Screening

    Key Question 1. How accurate is screening performed by a primary care clinician in identifying children younger than 5 years who are at increased risk of future dental caries?

    See KQ2b for screening, which addresses the same question.

    Benefits of Intervention

    Key Question 2. How effective is parental or caregiver/guardian oral health education provided by a primary care clinician in preventing dental caries in children younger than 5 years?

    One new fair-quality trial (n = 104) found oral health education for mothers of caries-free children aged 12 to 36 months was associated with reduced risk of incident dental caries at 6 months vs usual care (13.5% vs 34.7%; relative risk [RR], 0.39 [95% CI, 0.18 to 0.85) (eTables 4 and 5 in the Supplement).16

    Key Question 3. How effective is referral by a primary care clinician to a dental health care professional in preventing dental caries in children younger than 5 years?

    No study directly evaluated the effects of referral by a primary care clinician to a dental care professional on caries incidence. Although 6 observational studies (n = 92 476) (1 included in the prior USPSTF review17 and 5 new18-22) of children enrolled in Medicaid compared receiving a preventive dental visit from a dentist vs primary care clinician or earlier vs later first preventive dental visit, the studies were not designed to determine the referral source or effects of dental referral from primary care vs no referral (eTables 6 and 7 in the Supplement). In addition, results in some studies indicating an association between a dentist or earlier preventive visit and increased likelihood of subsequent caries-related treatment or caries burden are susceptible to confounding by indication related to the need for dental services.

    Key Question 4. How effective are preventive interventions (dietary fluoride supplementation, topical fluoride application, silver diamine fluoride, or xylitol) in preventing dental caries in children younger than 5 years?

    Dietary Fluoride Supplementation

    We identified no new trials published since the 2004 or 2014 USPSTF reviews.8,50 One randomized trial of Taiwanese 2-year old children with cleft lip (n = 140, fluoridation <0.1 ppm F) found 0.25-mg fluoride drops or chews associated with significantly decreased caries increment vs no supplementation (mean dmft reduction, 72% [P = .001] and 52% [P = .01], respectively).23 Four nonrandomized controlled intervention studies (n = 2273) included in the prior USPSTF review8 also found dietary fluoride supplementation in settings with water fluoridation levels below 0.6 ppm F associated with decreased caries incidence vs no fluoride supplementation (mean dmft reduction, 32% to 69%).24-28

    Topical Fluoride Application

    Fifteen trials (5 trials29-33 in the prior USPSTF review and 10 new trials34-45) evaluated topical fluoride (eTables 8 and 9 in the Supplement). Sample sizes ranged from 123 to 2536 (total 9541 participants). Two trials33,44,45 (n = 1376) were conducted in communities with adequate drinking water fluoridation, defined as 0.7 ppm F or greater. The mean age of enrolled children was 1 year to younger than 2 years in 6 trials and 2 to 5 years in 9 trials (1 trial31 did not report mean age). Five trials30,34,38,39,42 were conducted in preschool or daycare settings and the others were conducted in clinics. Eight trials (including 6 of the new trials) were conducted in very high HDI countries or settings. All trials except for 144,45 evaluated children classified as being at higher risk, based on low socioeconomic status, high community prevalence of caries, high baseline caries burden, or low rates of oral health behaviors.

    One trial38 evaluated acidulated phosphate fluoride foam and the others evaluated fluoride varnish. Fluoride varnish was most commonly administered as 5% sodium fluoride every 6 months. Topical fluoride was administered by a dental health professional in all trials in which this information was reported. In all trials except for 3,29,30,38 oral health education was provided in addition to the randomized intervention. The duration of follow-up ranged from 1 to 3 years.

    Three trials were rated good quality37,39,43 and the rest fair quality (eTable 5 in the Supplement). Methodological limitations in the fair-quality trials included unclear randomization or allocation concealment methods, open-label design, or high attrition.

    Topical fluoride was associated with significant decreased caries increment (13 trials, n = 5733; mean difference, −0.94 [95% CI, −1.74 to −0.34]; I2 = 86%) (Figure 4) and decreased likelihood of incident caries (12 trials, n = 8177; RR, 0.80 [95% CI, 0.66 to 0.95]; I2 = 79%; absolute risk difference, −7% [95% CI, −12% to −2%]) (Figure 5) vs placebo or no varnish, with a number needed to treat to prevent 1 child with incident caries of 14 (95% CI, 8 to 50). Although statistical heterogeneity was present, results consistently favored topical fluoride in analyses stratified by use of cluster design, very high HDI setting, application frequency, preschool, baseline caries status, adequate community fluoridation, provision of additional oral health measures, risk of bias, or duration of follow-up, and there were no statistically significant interactions on these factors and caries outcomes (Table 1 and Table 2). Results were also similar when the trial of fluoride foam or the trial conducted in a non–high-risk population was excluded from the analysis. There was a significant interaction between age and effects of fluoride varnish on likelihood of incident caries but not caries increment. In trials in which the mean age was younger than 2 years, fluoride varnish was associated with significant decreased likelihood of incident caries (5 trials, n = 3669; RR, 0.60 [95% CI, 0.39 to 1.03]; I2 = 49%),33,36-38,40 with no significant difference in trials in which the mean age was 2 years or older (7 trials, n = 4508; RR, 0.92 [95% CI, 0.81 to 1.01]; I2 = 42%; P = .008 for interaction).30,31,34,39,42,43,45

    No trial evaluated effects of topical fluoride on quality of life, function, or other noncaries outcomes.

    Xylitol

    No new trials of xylitol vs no xylitol were identified. Two fair-quality trials (n = 115 and n = 44) included in the prior USPSTF review found xylitol tablets or wipes associated with decreased caries increment or likelihood or incident caries, but estimates were imprecise.46,47

    Silver Diamine Fluoride

    No study of silver diamine fluoride met inclusion criteria.

    Harms of Intervention

    Key Question 5. What are the harms of specific oral health interventions to prevent dental caries in children younger than 5 years (parental or caregiver/guardian oral health education, referral to a dental health care professional, and preventive interventions)?

    The prior USPSTF review included a systematic review of 19 studies that found an association between early childhood fluoride supplementation and risk of fluorosis of the permanent dentition. Studies were observational and had methodological shortcomings, including use of recall to determine exposures.49 In studies that recorded supplement use at the time of exposure, odds ratios for dental fluorosis ranged from 4.2 to 15.6. No new study evaluated the association between fluoride supplementation and risk of fluorosis.

    Four new trials (n = 4141) reported no significant differences between fluoride varnish vs placebo or no varnish in risk of fluorosis or the likelihood of any adverse event.34-36,44,45,48 Two studies (n = 2864) reported that children did not like the smell of the fluoride varnish, and 1 study reported that a few children vomited due to the smell, texture, or taste.34-36

    Discussion

    Table 3 summarizes the evidence reviewed for this update. As in the prior USPSTF review,7,8 there remained no direct evidence on screening vs no screening for dental caries in children younger than 5 years. Evidence on the accuracy of primary care clinician examination in identifying caries lesions or predicting caries incidence in this population remained very limited, with no new studies. One new study found a novel caries risk assessment tool in 1-year-old children associated with suboptimal diagnostic accuracy for predicting future caries.15 Although other caries risk assessment instruments are available, they did not meet inclusion criteria because they were not administered by primary care clinicians or in primary care settings. These instruments often incorporate findings from an oral examination by a dental health professional and include tests not commonly obtained or available in primary care.51,52

    Evidence on the effectiveness of parental or caregiver oral health education also remains very limited. One new trial found oral health education for mothers of caries-free children associated with reduced risk of incident dental caries vs usual care, but the study was relatively small and conducted in Iran, potentially reducing applicability to the US.16 No study directly evaluated effects of referral by a primary care clinician to a dentist. Observational studies that compared children enrolled in Medicaid who received a preventive dental visit from a dentist vs a pediatrician are available but difficult to interpret due to confounding related to need for dental services.19-22 In addition, these studies did not evaluate referral source and did not compare dental referral vs no referral.

    No new trial evaluated fluoride supplementation. Prior USPSTF reviews found dietary fluoride supplementation associated with reduced caries incidence in children younger than 5 years in settings primarily with water fluoridation levels less than 0.6 ppm F, largely based on nonrandomized controlled intervention studies.53 There was also no new evidence on the association between early childhood intake of dietary fluoride supplementation and risk of enamel fluorosis. A systematic review included in the prior USPSTF review found an association between early childhood ingestion of systemic fluoride and enamel fluorosis of the permanent dentition.49 Severe fluorosis remains uncommon in the US (prevalence <2%).54

    Findings regarding topical fluoride are strengthened by the inclusion of 10 new trials. In addition to increasing the precision of estimates, 6 new trials were conducted in very high HDI settings (compared with 2 of 5 prior trials), potentially increasing applicability to US primary care settings. Topical fluoride was associated with improved outcomes, with a number needed to treat to prevent 1 child with incident caries of about 14 (95% CI, 8 to 50). Topical fluoride was administered as a varnish in all trials except for 1,30 which used acidulated phosphate fluoride foam. Results were consistent in stratified analyses on multiple factors, including community water fluoridation status. Although there was a significant interaction between younger age and larger reduction in likelihood of incident caries with topical fluoride, there was no significant interaction between age and effects on caries burden. Because almost all trials were conducted in higher-risk children, the applicability of findings to children not at increased risk is uncertain. In all trials the varnish was applied by dental personnel, although fluoride varnish can be successfully applied easily and with minimal training.55,56 Limited evidence on harms associated with topical fluoride indicated no increased risk of fluorosis48 or adverse events44,45 vs placebo. Serious adverse events were not reported, though some children had difficulty tolerating the varnish application because of odor or taste.

    Evidence on other preventive interventions was limited or unavailable. There were no new trials of xylitol in children younger than 5 years, and evidence in the prior USPSTF review was limited to 2 trials with imprecise estimates.46,47 Silver diamine fluoride has primarily been used as a treatment for arresting existing cavitated caries, but is also being evaluated for caries prevention. No trial evaluated silver diamine fluoride for prevention of caries in children younger than 5 years, although trials in US school-aged children are expected to be completed in 2023.57,58

    Limitations

    This review has several limitations. First, non–English-language articles were excluded. However, no non–English-language articles that appeared likely to affect conclusions were identified. Second, the review did not search for studies published only as abstracts and did not formally assess for publication bias with graphical or statistical methods because of differences in study design, populations, and outcomes assessed, with substantial statistical heterogeneity. Third, statistical heterogeneity was substantial in meta-analyses of topical fluoride. However, results were consistent in prespecified stratified analyses based on factors related to study design, population characteristics, intervention characteristics, and setting, and meta-analysis used a random-effects model. Fourth, some trials were conducted in countries and settings in which oral health care and behaviors may differ substantially from typical US primary care settings, potentially reducing applicability. Fifth, most studies had methodological limitations, reducing certainty in findings, and some KQs and interventions were addressed by little or no evidence.

    Conclusions

    There was no direct evidence on benefits and harms of primary care oral health screening or referral to dentist. Dietary fluoride supplementation and fluoride varnish were associated with improved caries outcomes in higher-risk children and settings.

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    Article Information

    Corresponding Author: Roger Chou, MD, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code BICC, Portland, OR 97239 (chour@ohsu.edu).

    Accepted for Publication: August 30, 2021.

    Author Contributions: Dr Chou had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Chou, Dana.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Chou, Pappas, Dana, Selph, Hart, Fu.

    Critical revision of the manuscript for important intellectual content: Chou, Schwarz.

    Statistical analysis: Chou, Dana, Fu.

    Obtained funding: Chou.

    Administrative, technical, or material support: Pappas, Dana, Hart, Schwarz.

    Supervision: Chou.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This research was funded under contract HHSA290201500009i, PRISM order HHSA29032014T, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force.

    Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

    Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project: Agency for Healthcare Research and Quality Medical Officer Iris Mabry-Hernandez, MD, MPH, as well as members of the US Preventive Services Task Force. The USPSTF members, expert consultants, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

    Additional Information: A draft version of this evidence report underwent external peer review from 5 content experts and 4 federal partners (Centers for Disease Control and Prevention, National Institute on Minority Health and Health Disparities, US Food and Drug Administration, and National Institute of Dental and Craniofacial Research). Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.

    Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.

    References
    1.
     Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999-2004 to 2011-2016. Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2019.
    2.
    Dye  BA, Mitnik  GL, Iafolla  TJ, Vargas  CM.  Trends in dental caries in children and adolescents according to poverty status in the United States from 1999 through 2004 and from 2011 through 2014.   J Am Dent Assoc. 2017;148(8):550-565. doi:10.1016/j.adaj.2017.04.013PubMedGoogle ScholarCrossref
    3.
    Dooley  D, Moultrie  NM, Heckman  B, Gansky  SA, Potter  MB, Walsh  MM.  Oral health prevention and toddler well-child care: routine integration in a safety net system.   Pediatrics. 2016;137(1):e20143532. doi:10.1542/peds.2014-3532PubMedGoogle Scholar
    4.
    Institute of Medicine; National Research Council.  Improving Access to Oral Health Care for Vulnerable and Underserved Populations. National Academies Press; 2011.
    5.
    Nicolae  A, Levin  L, Wong  PD,  et al.  Identification of early childhood caries in primary care settings.   Paediatr Child Health. 2018;23(2):111-115. doi:10.1093/pch/pxx155PubMedGoogle ScholarCrossref
    6.
    Moyer  VA; US Preventive Services Task Force.  Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.   Pediatrics. 2014;133(6):1102-1111. doi:10.1542/peds.2014-0483PubMedGoogle ScholarCrossref
    7.
    Chou  R, Cantor  A, Zakher  B, Mitchell  JP, Pappas  M.  Preventing dental caries in children <5 years: systematic review updating USPSTF recommendation.   Pediatrics. 2013;132(2):332-350. doi:10.1542/peds.2013-1469PubMedGoogle ScholarCrossref
    8.
    Chou  R, Cantor  A, Zakher  B,  et al.  Prevention of Dental Caries in Children Younger Than 5 Years Old: Systematic Review to Update the US Preventive Services Task Force Recommendation. Evidence Synthesis No. 104. Agency for Healthcare Research and Quality; 2014. AHRQ publication 12-05170-EF-1.
    9.
    Chou  R, Pappas  M, Dana  T, Selph  S, Hart  E, Schwarz  E.  Screening and Prevention of Dental Caries in Children Younger Than Five Years of Age: A Systematic Review for the US Preventive Services Task Force. Evidence Synthesis No. 210. Agency for Healthcare Research and Quality; 2021. AHRQ publication 21-05279-EF-1.
    10.
    Procedure Manual. US Preventive Services Task Force. Published May 2021. Accessed August 31, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
    11.
    Higgins  JP, Thompson  SG.  Quantifying heterogeneity in a meta-analysis.   Stat Med. 2002;21(11):1539-1558. doi:10.1002/sim.1186PubMedGoogle ScholarCrossref
    12.
    Human Development Report 2020: Reader's Guide. United Nations Development Programme. Accessed August 6, 2021. http://hdr.undp.org/en/content/human-development-report-2020-readers-guide
    13.
    Pierce  KM, Rozier  RG, Vann  WF  Jr.  Accuracy of pediatric primary care providers’ screening and referral for early childhood caries.   Pediatrics. 2002;109(5):E82-E2. doi:10.1542/peds.109.5.e82PubMedGoogle ScholarCrossref
    14.
    Serwint  JR, Mungo  R, Negrete  VF, Duggan  AK, Korsch  BM.  Child-rearing practices and nursing caries.   Pediatrics. 1993;92(2):233-237.PubMedGoogle Scholar
    15.
    MacRitchie  HM, Longbottom  C, Robertson  M,  et al.  Development of the Dundee Caries Risk Assessment Model (DCRAM)—risk model development using a novel application of CHAID analysis.   Community Dent Oral Epidemiol. 2012;40(1):37-45. doi:10.1111/j.1600-0528.2011.00630.xPubMedGoogle ScholarCrossref
    16.
    Basir  L, Rasteh  B, Montazeri  A, Araban  M.  Four-level evaluation of health promotion intervention for preventing early childhood caries: a randomized controlled trial.   BMC Public Health. 2017;17(1):767. doi:10.1186/s12889-017-4783-9PubMedGoogle ScholarCrossref
    17.
    Beil  H, Rozier  RG, Preisser  JS, Stearns  SC, Lee  JY.  Effect of early preventive dental visits on subsequent dental treatment and expenditures.   Med Care. 2012;50(9):749-756. doi:10.1097/MLR.0b013e3182551713PubMedGoogle ScholarCrossref
    18.
    Beil  H, Rozier  RG, Preisser  JS, Stearns  SC, Lee  JY.  Effects of early dental office visits on dental caries experience.   Am J Public Health. 2014;104(10):1979-1985. doi:10.2105/AJPH.2013.301325PubMedGoogle ScholarCrossref
    19.
    Blackburn  J, Morrisey  MA, Sen  B.  Outcomes associated with early preventive dental care among Medicaid-enrolled children in Alabama.   JAMA Pediatr. 2017;171(4):335-341. doi:10.1001/jamapediatrics.2016.4514PubMedGoogle ScholarCrossref
    20.
    Kranz  AM, Rozier  RG, Preisser  JS, Stearns  SC, Weinberger  M, Lee  JY.  Preventive services by medical and dental providers and treatment outcomes.   J Dent Res. 2014;93(7):633-638. doi:10.1177/0022034514536731PubMedGoogle ScholarCrossref
    21.
    Kranz  AM, Rozier  RG, Preisser  JS, Stearns  SC, Weinberger  M, Lee  JY.  Comparing medical and dental providers of oral health services on early dental caries experience.   Am J Public Health. 2014;104(7):e92-e99. doi:10.2105/AJPH.2014.301972PubMedGoogle ScholarCrossref
    22.
    Sen  B, Blackburn  J, Kilgore  ML,  et al.  Preventive dental care and long-term dental outcomes among ALL Kids enrollees.   Health Serv Res. 2016;51(6):2242-2257. doi:10.1111/1475-6773.12469PubMedGoogle ScholarCrossref
    23.
    Lin  YT, Tsai  CL.  Comparative anti-caries effects of tablet and liquid fluorides in cleft children.   J Clin Dent. 2000;11(4):104-106. PubMedGoogle Scholar
    24.
    Hamberg  L.  Controlled trial of fluoride in vitamin drops for prevention of caries in children.   Lancet. 1971;1(7696):441-442. doi:10.1016/S0140-6736(71)92426-3PubMedGoogle ScholarCrossref
    25.
    Hennon  DK, Stookey  GK, Muhler  JC.  Prophylaxis of dental caries: relative effectiveness of chewable fluoride preparations with and without added vitamins.   J Pediatr. 1972;80(6):1018-1021. doi:10.1016/S0022-3476(72)80016-7PubMedGoogle ScholarCrossref
    26.
    Hu  D, Wan  H, Li  S.  The caries-inhibiting effect of a fluoride drop program: a 3-year study on Chinese kindergarten children.   Chin J Dent Res. 1998;1(3):17-20.PubMedGoogle Scholar
    27.
    Margolis  FJ, Macauley  J, Freshman  E.  The effects of measured doses of fluoride: a five-year preliminary report.   Am J Dis Child. 1967;113(6):670-672. doi:10.1001/archpedi.1967.02090210084007PubMedGoogle ScholarCrossref
    28.
    Margolis  FJ, Reames  HR, Freshman  E, MaCauley  CD, Mehaffey  H.  Flouride: ten-year prospective study of deciduous and permanent dentition.   Am J Dis Child. 1975;129(7):794-800. doi:10.1001/archpedi.1975.02120440020006PubMedGoogle ScholarCrossref
    29.
    Frostell  G, Birkhed  D, Edwardsson  S,  et al.  Effect of partial substitution of invert sugar for sucrose in combination with Duraphat treatment on caries development in preschool children: the Malmö Study.   Caries Res. 1991;25(4):304-310. doi:10.1159/000261381PubMedGoogle ScholarCrossref
    30.
    Jiang  H, Bian  Z, Tai  BJ, Du  MQ, Peng  B.  The effect of a bi-annual professional application of APF foam on dental caries increment in primary teeth: 24-month clinical trial.   J Dent Res. 2005;84(3):265-268. doi:10.1177/154405910508400311PubMedGoogle ScholarCrossref
    31.
    Lawrence  HP, Binguis  D, Douglas  J,  et al.  A 2-year community-randomized controlled trial of fluoride varnish to prevent early childhood caries in Aboriginal children.   Community Dent Oral Epidemiol. 2008;36(6):503-516. doi:10.1111/j.1600-0528.2008.00427.xPubMedGoogle ScholarCrossref
    32.
    Slade  GD, Bailie  RS, Roberts-Thomson  K,  et al.  Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial.   Community Dent Oral Epidemiol. 2011;39(1):29-43. doi:10.1111/j.1600-0528.2010.00561.xPubMedGoogle ScholarCrossref
    33.
    Weintraub  JA, Ramos-Gomez  F, Jue  B,  et al.  Fluoride varnish efficacy in preventing early childhood caries.   J Dent Res. 2006;85(2):172-176. doi:10.1177/154405910608500211PubMedGoogle ScholarCrossref
    34.
    Agouropoulos  A, Twetman  S, Pandis  N, Kavvadia  K, Papagiannoulis  L.  Caries-preventive effectiveness of fluoride varnish as adjunct to oral health promotion and supervised tooth brushing in preschool children: a double-blind randomized controlled trial.   J Dent. 2014;42(10):1277-1283. doi:10.1016/j.jdent.2014.07.020PubMedGoogle ScholarCrossref
    35.
    Anderson  M, Dahllöf  G, Soares  FC, Grindefjord  M.  Impact of biannual treatment with fluoride varnish on tooth-surface–level caries progression in children aged 1-3 years.   J Dent. 2017;65:83-88. doi:10.1016/j.jdent.2017.07.009PubMedGoogle ScholarCrossref
    36.
    Anderson  M, Dahllöf  G, Twetman  S, Jansson  L, Bergenlid  AC, Grindefjord  M.  Effectiveness of early preventive intervention with semiannual fluoride varnish application in toddlers living in high-risk areas: a stratified cluster-randomized controlled trial.   Caries Res. 2016;50(1):17-23. doi:10.1159/000442675PubMedGoogle ScholarCrossref
    37.
    Jiang  EM, Lo  EC, Chu  CH, Wong  MC.  Prevention of early childhood caries (ECC) through parental toothbrushing training and fluoride varnish application: a 24-month randomized controlled trial.   J Dent. 2014;42(12):1543-1550. doi:10.1016/j.jdent.2014.10.002PubMedGoogle ScholarCrossref
    38.
    Latifi-Xhemajli  B, Begzati  A, Veronneau  J, Kutllovci  T, Rexhepi  A.  Effectiveness of fluoride varnish four times a year in preventing caries in the primary dentition: a 2 year randomized controlled trial.   Community Dent Health. 2019;36(2):190-194. doi:10.1922/CDH_4453Begzati05PubMedGoogle Scholar
    39.
    McMahon  AD, Wright  W, Anopa  Y,  et al.  Fluoride varnish in nursery schools: a randomised controlled trial—Protecting Teeth @3.   Caries Res. 2020;54(3):274-282. doi:10.1159/000509680PubMedGoogle ScholarCrossref
    40.
    Memarpour  M, Dadaein  S, Fakhraei  E, Vossoughi  M.  Comparison of oral health education and fluoride varnish to prevent early childhood caries: a randomized clinical trial.   Caries Res. 2016;50(5):433-442. doi:10.1159/000446877PubMedGoogle ScholarCrossref
    41.
    Memarpour  M, Fakhraei  E, Dadaein  S, Vossoughi  M.  Efficacy of fluoride varnish and casein phosphopeptide-amorphous calcium phosphate for remineralization of primary teeth: a randomized clinical trial.   Med Princ Pract. 2015;24(3):231-237. doi:10.1159/000379750PubMedGoogle ScholarCrossref
    42.
    Muñoz-Millán  P, Zaror  C, Espinoza-Espinoza  G,  et al.  Effectiveness of fluoride varnish in preventing early childhood caries in rural areas without access to fluoridated drinking water: a randomized control trial.   Community Dent Oral Epidemiol. 2018;46(1):63-69. doi:10.1111/cdoe.12330PubMedGoogle ScholarCrossref
    43.
    Oliveira  BH, Salazar  M, Carvalho  DM, Falcão  A, Campos  K, Nadanovsky  P.  Biannual fluoride varnish applications and caries incidence in preschoolers: a 24-month follow-up randomized placebo-controlled clinical trial.   Caries Res. 2014;48(3):228-236. doi:10.1159/000356863PubMedGoogle ScholarCrossref
    44.
    Tickle  M, O'Neill  C, Donaldson  M,  et al.  A randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services: the Northern Ireland Caries Prevention In Practice (NIC-PIP) trial.   Health Technol Assess. 2016;20(71):1-96. doi:10.3310/hta20710PubMedGoogle ScholarCrossref
    45.
    Tickle  M, O’Neill  C, Donaldson  M,  et al.  A randomized controlled trial of caries prevention in dental practice.   J Dent Res. 2017;96(7):741-746. doi:10.1177/0022034517702330PubMedGoogle ScholarCrossref
    46.
    Zhan  L, Cheng  J, Chang  P,  et al.  Effects of xylitol wipes on cariogenic bacteria and caries in young children.   J Dent Res. 2012;91(7)(suppl):85S-90S. doi:10.1177/0022034511434354PubMedGoogle Scholar
    47.
    Oscarson  P, Lif Holgerson  P, Sjöström  I, Twetman  S, Stecksén-Blicks  C.  Influence of a low xylitol-dose on mutans streptococci colonisation and caries development in preschool children.   Eur Arch Paediatr Dent. 2006;7(3):142-147. doi:10.1007/BF03262555PubMedGoogle ScholarCrossref
    48.
    Dos Santos  AP, Malta  MC, de Marsillac  MW, de Oliveira  BH.  Fluoride varnish applications in preschoolers and dental fluorosis in permanent incisors: results of a nested-cohort study within a clinical trial.   Pediatr Dent. 2016;38(5):414-418.PubMedGoogle Scholar
    49.
    Ismail  AI, Hasson  H.  Fluoride supplements, dental caries and fluorosis: a systematic review.   J Am Dent Assoc. 2008;139(11):1457-1468. doi:10.14219/jada.archive.2008.0071PubMedGoogle ScholarCrossref
    50.
    Bader  JD, Rozier  G, Harris  R,  et al.  Dental Caries Prevention: The Physician's Role in Child Oral Health Systematic Evidence Review. Agency for Healthcare Research and Quality; 2004.
    51.
    Harris  R, Nicoll  AD, Adair  PM, Pine  CM.  Risk factors for dental caries in young children: a systematic review of the literature.   Community Dent Health. 2004;21(1)(suppl):71-85.PubMedGoogle Scholar
    52.
    Holgerson  PL, Twetman  S, Stecksèn-Blicks  C.  Validation of an age-modified caries risk assessment program (Cariogram) in preschool children.   Acta Odontol Scand. 2009;67(2):106-112. doi:10.1080/00016350802714734PubMedGoogle ScholarCrossref
    53.
    Bader  JD, Rozier  RG, Lohr  KN, Frame  PS.  Physicians’ roles in preventing dental caries in preschool children: a summary of the evidence for the US Preventive Services Task Force.   Am J Prev Med. 2004;26(4):315-325. doi:10.1016/j.amepre.2003.12.001PubMedGoogle ScholarCrossref
    54.
    Wiener  RC, Shen  C, Findley  P, Tan  X, Sambamoorthi  U.  Dental fluorosis over time: a comparison of National Health and Nutrition Examination Survey data from 2001-2002 and 2011-2012.   J Dent Hyg. 2018;92(1):23-29.PubMedGoogle Scholar
    55.
    Autio-Gold  J.  Recommendations for fluoride varnish use in caries management.   Dent Today. 2008;27(1):64-67.PubMedGoogle Scholar
    56.
    Bawden  JW.  Fluoride varnish: a useful new tool for public health dentistry.   J Public Health Dent. 1998;58(4):266-269. doi:10.1111/j.1752-7325.1998.tb03007.xPubMedGoogle ScholarCrossref
    57.
    Ruff  RR, Niederman  R.  Silver diamine fluoride versus therapeutic sealants for the arrest and prevention of dental caries in low-income minority children: study protocol for a cluster randomized controlled trial.   Trials. 2018;19(1):523. doi:10.1186/s13063-018-2891-1PubMedGoogle ScholarCrossref
    58.
    Ruff  RR, Niederman  R.  Comparative effectiveness of school-based caries prevention: a prospective cohort study.   BMC Oral Health. 2018;18(1):53. doi:10.1186/s12903-018-0514-6PubMedGoogle ScholarCrossref
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