Based on the available evidence, the task force has recommended that primary care clinicians prescribe oral fluoride supplementation beginning at age 6 months for children whose water supply is deficient in fluoride, and that they apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. These are “B” recommendations, and apply to all asymptomatic children younger than 5 years.
The task force also concluded that the current evidence is insufficient on performing routine oral screening examinations for dental caries by primary care clinicians in children younger than 5 years, and that the balance of benefits and harms of screening in this population cannot be determined — an “I” recommendation.
“Primary care clinicians have an important role in helping to prevent cavities in children under 5 years old,” said Michael Cabana, M.D., M.A., M.P.H., a member of the task force, in a USPSTF bulletin. “By applying fluoride varnish starting when children’s teeth first come in and prescribing fluoride supplements for children with low fluoride in their water supply, clinicians can help keep their young patients’ teeth healthy.”
Dental caries, also referred to as cavities or tooth decay, is one of the most common chronic childhood diseases in the United States. The CDC estimates that about 20% of children ages 5 to 11 years have at least one untreated decayed tooth. Left untreated, caries can cause pain and infection and may negatively affect a child’s ability to eat or speak.
The final recommendation statement, with only minor changes in language, accords with the task force’s May 2014 recommendation statement on the topic. In the 2014 recommendation, the task force 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 to the primary teeth of all infants and children beginning at the age of primary tooth eruption. The task force also stated in the 2014 recommendation that there was insufficient evidence to assess the balance of benefits and harms of routine screening for dental caries performed by primary care clinicians in children from birth to age 5 years. The AAFP supported the 2014 recommendation.
To update the 2014 recommendation, the USPSTF commissioned a systematic review on screening and interventions to prevent dental caries in children younger than 5 years. The review focused on three areas: screening for caries, assessment of risk for future caries, and the effectiveness of various interventions that have possible benefits in preventing caries.
The evidence review consisted of a search of studies published on Ovid MEDLINE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews from 2013 through September 2020, with additional surveillance conducted through July 23, 2021. Searches were supplemented by a reference list review of relevant systematic reviews, and studies from the prior evidence review that met inclusion criteria were carried forward.
A total of 32 studies and one systematic review were included. Of those, 17 studies were new for the update.
The USPSTF stated that the main findings of their evidence report were consistent with the task force’s prior evidence review.
No direct evidence was found to compare the effects on the incidence of dental caries and related outcomes between screening for dental caries by primary care clinicians in children younger than 5 years versus no screening.
Evidence on the accuracy of primary care clinician examination in identifying caries or predicting caries incidence was very limited, and evidence on the effectiveness of parental or caregiver oral health education on caries outcomes also remained very limited. No study directly evaluated the effects on oral health of referral by a primary care clinician to a dentist.
In terms of preventive interventions, while the task force found no new evidence on the effectiveness of dietary fluoride supplementation, evidence from previous reviews found that fluoride supplementation was effective at reducing caries incidence in children younger than 5 years in settings with water fluoridation levels less than 0.6 parts per million, based largely on results from nonrandomized trials.
As for topical fluoride, results from a combination of new trials and trials carried forward from the prior review found that fluoride varnish was associated with decreased caries increment and decreased likelihood of experiencing incident caries, with a number need to treat of about 14 in order to prevent one child with incident caries. Serious adverse events were not reported, although some children reported difficulty receiving the varnish because of odor or taste. In addition, because almost all the trials were conducted in children at increased risk for dental caries, the task force stated that these findings may not be as applicable to children who are not at increased risk.
Evidence on other preventive interventions, such as xylitol or silver diamine fluoride, was limited or not available.
The USPSTF noted several areas where additional research is needed. Specifically, the task force stated that more studies are necessary to confirm the benefits of fluoride varnish among children at lower risk for dental caries, determine the benefits and harms of silver diamine fluoride for the prevention of caries, and identify effective oral health educational and counseling interventions for parents and caregivers. They also called for more research to identify effective prevention measures in children in economically disadvantaged situations, and for studies that enroll sufficient numbers of patients from certain racial and ethnic populations to understand the benefits and harms of interventions in these groups.
In addition, the task force posted links to several new resources for clinicians and patients on its website. These include
The task force posted draft versions of the recommendation statement and evidence review on its website from May 11, 2021, to June 7, 2021.
In response to several commenters who expressed concerns about the risk of fluoride toxicity and barriers to fluoride prescriptions, the task force updated the Harms of Preventive Interventions section, added information on timing and dosage to the Practice Considerations section, and expanded the Additional Tools and Resources section to include the My Water’s Fluoride tool to assist clinicians in identifying fluoride levels in local water systems.
Other commenters requested that the task force recommend that primary care clinicians provide other interventions, such as health education. In response, the USPSTF stated that it described the evidence it reviewed on health education in the Supporting Evidence section.
The AAFP’s Commission on Health of the Public and Science plans to review the task force’s final recommendation statement, final evidence summary and evidence review, and will then determine the Academy’s stance on the recommendation.