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Prevention of Dental Caries in Children Younger Than 5 Years Old

Профилактика кариеса зубов у детей в возрасте до 5 лет

 

Keywords:

preschool children – дошкольники

fluoride varnish – фтор-лак

observation – наблюдение

Evidence – данные

caregiver/guardian – воспитатель/опекун

prevention – предотвращение

breakdown – разрушение

fermentable – брожение

to decay – распадаться

crowding – скученность

 

Background:

A 2004 U.S. Preventive Services Task Force (USPSTF) review recommended that primary care clinicians prescribe oral fluoride supplementation to preschool children over the age of 6 months whose primary water source is deficient in fluoride but found insufficient evidence to recommend for or against risk assessment of preschool children by primary care clinicians for the prevention of dental caries.

Purpose:

To systematically update the 2004 USPSTF review on prevention of dental caries in children younger than age 5 years by medical primary care clinicians.

Methods:

We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the 1st quarter of 2013) and Ovid MEDLINE® (1999 through March 8, 2013) and manually reviewed reference lists.

Results:

No randomized trial or observational study compared clinical outcomes between children younger than age 5 years screened and not screened by primary care clinicians for dental caries. One good-quality cohort study found primary care pediatrician examination following 2 hours of training associated with a sensitivity of 0.76 for identifying a child with one or morecavities and 0.63 for identifying children age <36 months in need of a dental referral compared with a pediatric dentist evaluation. No study evaluated the accuracy of risk-assessment tools applied by primary care clinicians to identify children younger than age 5 years at increased risk for future dental caries. We identified no new trials on the effects of oral fluoride supplementation in children younger than 5 years on dental caries outcomes. Three randomized trials published since the prior USPSTF review were consistent with three previous trials in finding fluoride varnish more effective than no fluoride varnish in reducing caries incidence in higher risk children younger than age 5 years (percent reduction in caries increment, 18 to 59%), although in all trials fluoride varnish was applied by dental personnel. Three trials reported no clear effects of xylitol versus no xylitol on caries incidence in children younger than 5 years. Five new observational studies in an updated systematic review were consistent with previous findings of an association between early childhood exposure to systemic fluoride and enamel fluorosis. Other than diarrhea, reported in two trials of xylitol, harms were poorly reported in trials of caries prevention interventions. Evidence on the effectiveness of educational or counseling interventions and the effectiveness of primary care referral to a dentist remains sparse or unavailable

Limitations:

Only English-language articles were included. Due to limited evidence from randomized trials, we included nonrandomized trials. Studies conducted in resource-poor settings may be of limited applicability to screening in the United States.

Conclusions:

Evidence previously reviewed by the USPSTF found oral fluoride supplementation effective at reducing caries incidence in children younger than age 5 years but associated with risk of enamel fluorosis. New evidence supports the effectiveness of professionally applied fluoride varnish at preventing caries in higher risk children younger than age 5 years. Research is needed to understand the accuracy of primary care oral health examination and caries risk assessment, primary care referral to dental care, and effective parental and caregiver/guardian educational and counseling interventions.

Introduction

 

Purpose and Previous U.S. Preventive Services Task Force Recommendation

This report was commissioned by the U.S. Preventive Services Task Force (USPSTF) in order to update its 2004 recommendation on prevention of dental caries by medical primary care clinicians in children younger than age 5 years.

In 2004, the USPSTF recommended that primary care clinicians prescribe dietary fluoride supplementation to children over the age of 6 months whose primary water source is deficient in fluoride (B recommendation).1 This recommendation was based on fair evidence that in young children with low fluoride exposure, prescription of dietary fluoride supplements by primary care clinicians is associated with reduced risk of dental caries that outweighs potential harms of enamel fluorosis, which in the United States is primarily manifested as mild cosmetic discoloration of teeth.

In 2004, the USPSTF also concluded that the evidence was insufficient to recommend for or against routine risk assessment of children younger than age 5 years by primary care clinicians for the prevention of dental disease (I recommendation). The USPSTF found no validated risk-assessment tools or algorithms for assessing dental disease risk by primary care clinicians and little evidence on the accuracy of primary care clinicians in assessing dental disease risk or in performing oral examinations. In addition, the USPSTF found little evidence on the effectiveness of counseling parents or referring high-risk children to dental care providers in reducing risk of caries and related dental disease. Therefore, the USPSTF concluded that there was insufficient evidence to determine the balance between benefits and harms of routine risk assessment to prevent dental disease in children younger than age 5 years.

Condition Definitions

Dental caries, or tooth decay, is an infectious process involving breakdown of the tooth enamel. Caries form through a complex interaction between cariogenic acid-producing bacteria in combination with fermentable carbohydrates and other dietary, genetic, behavioral, social, and cultural factors.

Children are susceptible to caries as soon as the first teeth appear, which usually occurs around age 6 months. Early childhood caries is defined as the presence of one or more decayed (noncavitated or cavitated), missing (due to caries), or filled toothsurfaces (dmf) in preschool-age children. The abbreviation dmfs refers to decayed, missing, or filled primary tooth surfaces, and dmft refers to decayed, missing, or filled primary teeth (one tooth may have more than one affected surface).

Prevalence and Burden of Disease

Dental caries is the most common chronic disease of children in the United States and is increasing in prevalence among young children. The National Health and Nutrition Examination Survey (NHANES) found that the prevalence of caries in primary teethin 2- to 5-year-olds increased from approximately 24 to 28 percent between the periods 1988 to 1994 and 1999 to 2004.Approximately three-quarters of children with caries had not received treatment for the condition.

Dental caries disproportionately affects minority and economically disadvantaged children. NHANES found that 54 percent of children age 2 to 11 years in families below the Federal poverty threshold experienced primary tooth dental caries, compared with one-third of children in families with incomes above 200 percent of the poverty threshold. Mexican-American children were more likely to experience dental caries in primary teeth (55%) than were black children (43%) or white children (39%), and were more likely to have untreated dental caries (33, 28, and 20%, respectively). In addition to higher prevalence, the severity of dental caries is also greater in economically disadvantaged and minority children.

Early childhood caries is associated with pain and loss of teeth, as well as impaired growth, decreased weight gain, and negative effects on quality of life. Repairs or extractions of carious teeth can be traumatic experiences for young children and occasionally result in serious complications. Early childhood caries is also associated with failure to thrive; can affect appearance, self-esteem, speech, and school performance; and is associated with future caries in both the primary and permanent dentitions.Premature loss of primary molars due to early childhood caries can result in loss of arch space, leading to crowding of thepermanent teeth, affecting aesthetics and potentially requiring orthodontic correction. In 2000, the U.S. Surgeon General estimated that over 50 million school hours are lost each year nationally due to dental-related concerns. More recent data indicate that more than 4 million school hours are lost each year due to dental care in the State of North Carolina, with over 700,000 of these hours lost due to dental pain or infection.