Primary care physicians (PCPs) who treat pediatric patients need to make oral fluoride supplementation part of routine care for children up to age 5 years, according to updated U.S. Preventive Services Task Force (USPSTF) guidelines.
According to two “B” grade recommendations (“moderate certainty” for “moderate net benefit”), pediatric PCPs should “prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride… 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,” Karina W. Davidson, PhD, MASc, of the Feinstein Institutes for Medical Research in New York City, and co-authors wrote.
However, routine screening for dental caries by PCPs in kids less than 5 years old is not supported based on current evidence (“I” grade for insufficient data), they wrote in JAMA. But Davidson’s group also advised that when “deciding whether to routinely perform screening examinations for dental caries in children from birth to age 5 years, clinicians should consider” such issues as preventing the burden of the chronic disease of dental caries, and the lack of harm cause by non-invasive screening.
Dental caries are more commonly known as cavities or tooth decay, and they are brought on by the breakdown of the outer layer of the tooth enamel, explained Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, in a JAMA Patient Page. She reiterated that “[s]creening examinations for dental caries are noninvasive and not likely to cause serious harm,” as it just requires that the clinician “look at the teeth for signs of decay and assess the whole mouth signs of poor oral hygiene.”
In a JAMA interview, task force member Michael Cabana, MD, MA, MPH, of the Albert Einstein College of Medicine in New York City, explained that the downside of fluoride supplementation is quite minor. “There is a very small, uncommon risk of getting too much fluoride and the fluorosis would cause discoloration of the teeth, but overall, that wasn’t reported significantly in the studies so we thought that the risk of that was very small, looking at the preponderance of evidence,” he said.
While there were no data that evaluated whether pediatric PCP referral to a dentist occurred for incidence of caries, according to Davidson’s group, pediatric PCPs need to stop letting patient dental health fall through the cracks, noted Melinda B. Clark, MD, of Albany Medical Center in Albany, New York, and Patricia A. Braun, MD, MPH, of Denver Health, in an accompanying editorial. A dental visit by age 1 year is called for by the American Academy of Pediatrics (AAP), American Academy of Pediatric Dentistry, and the American Dental Association (ADA), they pointed out.
“Yet only 2% of U.S. children will have seen a dentist by their first birthday, despite an estimated 10% already having dental caries,” they wrote, and that’s a problem because “[p]oor oral health adversely affects overall health, and dental caries is associated with pain, tooth loss, missed school days, poorer academic performance, and costly restorative care.”
Having said that, fitting dental care into the overall pediatric healthcare agenda can be difficult for clinicians and even parents. In a 2018 Contemporary Pediatrics article, Alison L Dickson, MD, and Margherita Fontana, DDS, PhD, both of the University of Michigan in Ann Arbor, acknowledged that “for most children—and most pediatricians—oral health is often buried in a long list of priorities. In my general pediatric clinic now, a terrified 2-year-old sits crying in her mother’s lap, the scars of prior cardiac surgeries on her chest. Dental caries dot her smile. ’Dentist?’ her mother repeats to me. She is too busy with the child’s many appointments, and her child is too frightened. How do I improve this child’s oral health during a short health-maintenance visit? I have minutes to spare, and mom’s motivation to change appears to be low.”
In a presentation at the 2019 AAP meeting, a group of physicians and dentists reported on a study in which they asked parents about “barriers to making or keeping the dental appointment” as recommended by a pediatricians. “Parents cited insurance coverage, unaffordable co-pays, transportation, lack of access to preferred dentist, patient age, and competing priorities as barriers to making or keeping dental appointments,” they said. “This subset of patients may benefit from alternate models of care such as co-location of dental health personnel in the primary care setting. Opportunities for improvement in physician-dentist collaboration should be explored.”
In a 2020 Pediatric Dentistry study, David Okuji, DDS, MBA, MS, of NYU Langone Health in New York City, and co-authors looked at national data for trends in pediatric patient visits to dentists and physicians and concluded that “[p]hysicians have an opportunity to address oral health in younger children, and dentists have an opportunity to address systemic health for older children.” For instance, children ages ≤5 years, should do dental referrals, while for kids ages ≥9 years, “dentists should provide counseling on healthy weight, nutrition, and human papillomavirus (HPV) vaccination; monitoring for diabetes and asthma; and screening for smoking, vaping, and sleep apnea.”
In an ADA-Elsevier Practice Update, Judith Haber PhD, APRN, of the NYU Rory Meyers College of Nursing in New York City, commented that the Okuji’s group neglected to mention the role other healthcare providers, such as family nurse practitioners and physician assistants, play in boosting “well-child care [and] integrating pediatric oral health with overall health… Nurse practitioner and physician assistant programs also have made significant strides in integrating oral health in their programs.”
That dovetails with Clark and Braun’s assertion that >80% of children have at least one visit with a non-dental healthcare professional by age 1 year, so “primary care clinicians are well-positioned to deliver preventive oral health services, which are proven to reduce caries in young children.”
Potential tools to deliver that care include the online tool “My Water’s Fluoride” from the CDC that helps determine the water fluoridation status of a community in order to prescribe appropriate oral fluoride supplementation, they noted.
As for the updated USPTSF recommendation, Clark and Braun said they were not radically different from the earlier 2014 iteration, but the 2021 version relies on “stronger [evidence], particularly for caries prevention with early application of fluoride varnish.”
That evidence was gathered by Roger Chou, MD, of Pacific Northwest Evidence-based Practice Center in Oregon Health & Science University in Portland, and co-authors who looked at 32 studies (n=106,684 patients), the majority of which were randomized controlled trials along with one systematic review that included 19 studies.
They reported in JAMA that one study (n=258) found primary care pediatrician examination was tied to a 0.76 (95% CI 0.55-0.91) sensitivity and a 0.95 (95% CI 0.92-0.98) specificity for identifying a child (age <36 months) with cavities. Another study found that the Dundee Caries Risk Assessment Model was linked with a 0.53 sensitivity and a 0.77 specificity (CIs not reported) for a child with future caries.
In terms of prevention, topical fluoride versus placebo or no topical fluoride was associated with decreased caries burden, for a mean caries increment—defined as the difference in decayed, missing, and filled teeth or surfaces—of −0.94 (95% CI −1.74 to −0.34). Topical fluoride also was tied to a decreased likelihood of incident caries (relative risk 0.80 [95% CI 0.66 to 0.95]; –7 absolute risk difference) in higher-risk populations or settings, but with no increased fluorosis risk.
Chou’s group stressed that “[f]indings regarding topical fluoride are strengthened by the inclusion of 10 new trials… 6 [of which]… were conducted in very high [Human Development Index] settings potentially increasing applicability to U.S. primary care settings.”
However, there were some data missing, according to the authors, who noted that there were no studies that evaluated effects of primary care screening on clinical outcomes, and no new trials on dietary fluoride supplementation were identified. Also, evidence backing other preventive interventions, such as the plant-based alcohol xylitol, were limited. And data on silver diamine fluoride (SDF) were not available, according to Chou’s group, although a seven-study 2017 systematic review reported that 30% and 38% concentrations of SDF showed potential as an alternative treatment for arresting caries in primary teeth and permanent first molars.
Clark and Braun cautioned that the current recommendation applies to children up to age 5 years, “whereas the 2014 USPSTF recommendations included children through age 5 years. The modified upper age parameter limits direct comparison of the guidelines.”
They also emphasized that dental caries “disproportionately affects children of low socioeconomic status and minority race and ethnicity, with a higher prevalence among Mexican American children (33%) and non-Hispanic Black children (28%) than among non-Hispanic White children (18%).”
Davidson’s and co-authors called for more studies on “risk assessment and preventive interventions should enroll sufficient numbers from certain racial and ethnic populations (eg, Black and Hispanic children) to understand the benefits and harms of interventions in these specific groups.”
A 2020 study in Preventing Chronic Disease advised that clinicians need to broaden their viewpoint and include the entire family when looking to boost oral care habits in their young patients, as “tooth brushing behaviors of young children are strongly associated with those of their parents and with the level of family support for brushing.”
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For children ages ≤5 years, primary care physicians (PCP)/pediatricians should prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, and apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption, according to the U.S. Preventive Services Task Force (USPSTF).
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The USPSTF concluded that there is insufficient evidence to assess the balance of benefits and harms of routine screening exams by PCPs/pediatricians for dental caries in children younger than 5 years.
Shalmali Pal, Contributing Writer, BreakingMED™
The USPSTF is funded by the Agency for Healthcare Research and Quality (AHRQ). The evidnce report was funded by AHRQ.
USPSTF members reported travel reimbursement and an honorarium for participating in USPSTF meetings.
Clark reported with Smiles for Life. Braun reported relationships with the Rocky Mountain Network for Oral Health.
Jin reported serving as JAMA associate editor.
Chou and co-authors reported no relationships relevant to the contents of this paper to disclose.
Cat ID: 138
Topic ID: 85,138,730,138,139,47,151,925
