Oral Health in Children and Adolescents Ages 5 to 17 Years: Screening and Preventive Interventions

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms to improve the health of people nationwide. 

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. 

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. 

The USPSTF is committed to mitigating the health inequities that prevent many people from fully benefiting from preventive services. Systemic or structural racism results in policies and practices, including health care delivery, that can lead to inequities in health. The USPSTF recognizes that race, ethnicity, and gender are all social rather than biological constructs. However, they are also often important predictors of health risk. The USPSTF is committed to helping reverse the negative impacts of systemic and structural racism, gender-based discrimination, bias, and other sources of health inequities, and their effects on health, throughout its work.

Oral health is fundamental to health and well-being across the lifespan.^1,2 Oral health conditions affect the daily lives of school-age children and adolescents, leading to loss of more than 51 million school hours every year.^3,4 Despite declines in untreated tooth decay in the primary teeth of young children,^5,6 dental caries remains one of the most common conditions of childhood, and prevalence of untreated caries increases as children age.^1,2,7 In the United States, oral health disparities are shaped by unequally affordable and accessible dental care and other disadvantages related to social determinants of health (e.g., living in a rural area or immigration status).^1,2,4,5 Black, Hispanic/Latino, Native American/Alaska Native, Asian, and Native Hawaiian/Pacific Islander children and adolescents are more likely to have dental caries compared with all children. Untreated oral health conditions in children can lead to serious infections and affect growth, development, and quality of life.^1,4,10

Due to a lack of evidence, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (e.g., dental caries) performed by primary care clinicians in asymptomatic children and adolescents ages 5 to 17 years.

Due to a lack of evidence, the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (e.g., dental caries) performed by primary care clinicians in asymptomatic children and adolescents ages 5 to 17 years.

See Table 1 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.¹¹

Patient Population Under Consideration

This recommendation applies to asymptomatic school-age children and adolescents ages 5 to 17 years. Interventions for children younger than age 5 years are addressed in a separate recommendation.

Definitions

Dental caries refers to a multifactorial disease process resulting in demineralization of the teeth.^10,12 Bacteria in the mouth metabolize sugars from food and drink to produce acids that erode tooth enamel.^1,2,10 When left untreated, demineralization can weaken and destroy the enamel, forming cavities and causing pain, infection, and tooth loss.² Oral health conditions for this recommendation statement refer to clinical health outcomes focused on presence and severity of dental caries, or caries burden (based on the number of affected teeth or surfaces), morbidity, quality of life, functional status, and harms of screening or treatment related to these conditions.¹ The USPSTF focused on dental caries as the most common oral health condition and the most potentially amenable to primary care interventions.

Screening Tests

Screening could include clinical assessments (e.g., physical examination) and standardized risk prediction tools or a combination of approaches by primary care clinicians to identify children who have existing oral health conditions or children who might most benefit from interventions to prevent future oral health outcomes due to increased risk.¹

Interventions

Reviewed interventions focused on preventing future dental caries, including counseling and health education toward reducing the burden of bacteria in the mouth, decreasing the frequency of refined sugar intake, and promoting resistance to caries in the teeth through use of fluoride, dental sealants, silver diamine fluoride (SDF), and xylitol.^1,2,13,14

Suggestions for Practice Regarding the I Statement

In deciding whether to routinely screen or deliver interventions to prevent oral health conditions, primary care clinicians should consider the following.

Potential Preventable Burden

Dental caries are a common chronic condition of childhood; in 2011 in the United States, over 50% of children ages 6 to 11 years had dental caries in primary teeth and 17% had caries in permanent teeth.^1,2 In the United States, an estimated 5.2% of children ages 6 to 11 years and 17% of adolescents ages 12 to 19 years had untreated dental caries in permanent teeth based on 2011 to 2016 data.^1,15 Developmental defects in teeth, inadequate salivary composition or flow, frequent intake of dietary sugars (in foods and beverages), suboptimal fluoride exposure, and oral hygiene practices (e.g., lack of tooth brushing and flossing) can increase susceptibility to dental caries.^1,2 Social determinants of health (nonbiological factors) associated with increased risk of oral health conditions include low socioeconomic status, lack of dental insurance, and living in communities with dental professional shortages, limiting access to dental care.^1,2

These inequities associated with social determinants of health can exacerbate and perpetuate oral health disparities.² For example, children experiencing poverty are more likely to experience food insecurity;² food insecurity is associated with increased intake of dietary refined sugars that elevates risk for dental caries.^2,16 Such disparities related to race, ethnicity and socioeconomic status also exist in receipt of preventive interventions.^1,4 For example, youth experiencing the highest levels of poverty are more likely to have dental caries (65%) compared with all youth (57%) but are less likely to have dental sealants on their permanent teeth (43%) than all youth (48%).¹

While evidence is limited on the prevalence of periodontal disease in children and adolescents,¹ risk in pregnant youth may be elevated.⁴

Potential Harms

Primary care screening approaches (e.g., oral clinical assessments or standardized risk assessment instruments) to identify children with early untreated dental caries or children at increased risk for developing future dental caries are noninvasive and would seem unlikely to cause serious harms, but evidence is lacking. Health education and counseling to improve oral hygiene and reduce modifiable risk factors (e.g., frequent intake of refined sugars) are also noninvasive.

Current Practice

The USPSTF found little evidence on current practices in primary care for screening or performing interventions to prevent dental caries in children ages 5 to 17 years. There are well-known significant barriers to providing oral health services in the primary care setting; oral health care and general health care operate as almost entirely separate systems, from training to financing and service settings.^2,4 Primary care clinicians have variable access and familiarity with oral health interventions.^1,4 As a result, oral health care delivery by primary care clinicians will likely require additional training and specific equipment to deliver screening and interventions.^1,2 Primary care clinicians may also have reimbursement challenges and face administrative obstacles to making dental referrals and linking patients to dental care.¹ The USPSTF recommends oral fluoride supplements for children younger than age 5 years starting at age 6 months with water sources deficient in fluoride and administration of varnish to the primary teeth of all children younger than age 5 after tooth eruption.¹⁷ It is unknown how frequently fluoride is administered in older children and adults.

Additional Tools and Resources

The Health Resources and Services Administration’s oral health factsheet (https://www.hrsa.gov/sites/default/files/hrsa/oral-health/oral-health-2016-factsheet.pdf) and report on Integration of Oral Health and Primary Care Practice (https://www.hrsa.gov/sites/default/files/hrsa/oral-health/integration-oral-health.pdf) emphasize optimal collaborations between primary care clinicians and oral health professionals.

The U.S. Department of Health and Human Services’ Report of the Surgeon General (https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf) and the National Institutes of Health’s report Oral Health in America: Advances and Challenges (https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf) comprehensively describe the importance of oral health to overall health and highlight advances and challenges toward improving oral health in the United States.

The Community Preventive Services Task Force recommends fluoridation of community water sources to reduce dental caries (https://www.thecommunityguide.org/findings/dental-caries-cavities-community-water-fluoridation) and school-based dental sealant delivery programs to prevent dental caries (https://www.thecommunityguide.org/findings/dental-caries-cavities-school-based-dental-sealant-delivery-programs.html).

Other Related USPSTF Recommendations

The USPSTF has issued recommendations on screening and interventions to prevent dental caries in children younger than age 5 years¹⁷ and screening and preventive interventions for oral health in adults (in progress).

Scope of Review

The USPSTF commissioned a systematic evidence review¹ to evaluate the benefits and harms of screening and preventive interventions for oral health conditions in children and adolescents ages 5 to 17 years. The USPSTF previously addressed counseling to prevent dental and periodontal disease (1996) and, most recently, screening and interventions to prevent dental caries in children younger than age 5 years (2021). Concurrently, the USPSTF commissioned a systematic evidence review to evaluate the benefits and harms of oral health screening and preventive interventions in adults;¹⁸ this recommendation is addressed in a separate statement.

Accuracy of Screening Tests

The USPSTF reviewed limited evidence on screening to identify children and adolescents with oral health conditions in the primary care setting. The review identified a single observational study (n=632)¹⁹ assessing diagnostic accuracy using visual screening by a registered nurse (n=219) or a 17-item questionnaire (n=305) completed by parents or guardians to identify untreated dental caries in children ages 5 to 12 years.^1,19 The nurses received 5 hours of training along with written materials on screening and diagnoses.^1,19 The visual screening approach was associated with a sensitivity of 0.92 (95% CI, 0.84 to 0.97) and a specificity of 0.993 (95% CI, 0.96 to 0.9998).^1,19 The questionnaire, which included items on the condition of the child’s mouth and socioeconomic and sociodemographic factors, was associated with a sensitivity of 0.69 (95% CI, 0.60 to 0.77) and a specificity of 0.88 (95% CI, 0.83 to 0.93).^1,19

The review found no evidence on screening to identify children or adolescents ages 5 to 17 years at increased risk for future oral health outcomes.¹

Effectiveness of Screening

The review identified no evidence on the effectiveness of screening on future oral health outcomes.¹

Harms of Screening

The review identified no evidence on the harms of screening.¹

Effectiveness of Preventive Interventions

While the USPSTF sought evidence of interventions to prevent a broad collection of oral health conditions that could be addressed in the primary care setting, identified studies focused on dental caries interventions performed by dental health professionals in a dental setting.

The USPSTF also sought evidence on the effectiveness of oral health behavioral counseling by the primary care clinician on oral health outcomes, and the effectiveness of referrals by primary care clinicians to dental professionals to prevent oral health conditions. However, the review identified no evidence on the effectiveness of these interventions. For counseling, there were no eligible studies for review in school-age children and adolescents. Current evidence is limited to dental professional–led or school-based education or counseling, often combined with other interventions; the counseling interventions were of uncertain feasibility to the primary care setting or reported intermediate outcomes (e.g., effects of interventions on beliefs about oral health) rather than direct dental health outcomes.¹ The following discussion focuses on preventive medications. Studies often had significant methodological limitations (e.g., high attrition, unclear randomization, or uncertain applicability to the United States) and did not report analysis by race, socioeconomic status, or other important social determinants of health. Studies inconsistently reported community water fluoridation levels or whether participants received oral health education, precluding evaluation of the effectiveness of these factors on oral health outcomes. Studies focused on dental caries outcomes measured as DMFT/DFT (Decayed, Missing, and Filled Teeth/Decayed, Filled Teeth) or DMFS/DFS (Decayed, Missing, and Filled Surfaces/Decayed, Filled Surfaces) increment, with limited evidence on nonoral health outcomes such as quality of life or functional status, including school-related outcomes.

Fluoride

Among seven trials that evaluated fluoride supplements vs. placebo or no fluoride in children age 5 years or older (n=3,382),¹ one trial of self-administered fluoride supplements at home with low adherence found no benefit on stratified analysis (n=438; mean difference, 0.13 [95% CI, -0.38 to 0.64]).¹ In six other trials of supplements supervised at school, intake of fluoride supplements was associated with decreased dental caries increment in permanent teeth (6 trials; effective n=1,395; mean difference, -0.73 [95% CI, -1.30 to -0.19]).¹

Similarly, in a systematic review (26 trials) evaluating application of topical fluoride gel vs. placebo or no gel in children ages 5 to 15 years, gel was applied at school in 19 trials or in a dental clinic in seven trials.¹ Dental professionals applied gel in 15 trials while gels were self-applied and supervised by a dental hygienist or other nondental professional adult in 11 trials.¹ Topical gels were associated with decreased dental caries burden in permanent teeth at about 3 years (based on the DFT or DMFT score) (10 trials; n=3,198; prevented fraction, 0.32 [95% CI, 0.19 to 0.46]; prevented fraction is the difference in increment between the control and intervention groups, divided by the control group increment).¹

In a systematic review (14 trials) of fluoride varnish administered exclusively by dental professionals in school settings to children age 5 years or older, varnish was associated with decreased dental caries burden at 1 to 4.5 years based on the DMFS or DFS score (14 trials; n=3,419; prevented fraction, 0.43 [95% CI, 0.30 to 0.57]; I²=75%) or DMFT or DFT score (5 trials; n=3,902; prevented fraction, 0.44 [95% CI, 0.11 to 0.76]; I²=86%).¹ A subsequent trial (n=5,397) reported findings consistent with the systematic review.¹

Sealants, SDF, and Xylitol

In a systematic review (7 trials) of resin-based sealants administered by dental health professionals in dental settings to children ages 5 to 10 years, sealants were associated with decreased risk of dental caries in the first molars at 2 years (7 trials; n=1,322; odds ratio, 0.12 [95% CI, 0.08 to 0.19]; I²=72%).¹ Another systematic review (2 trials) and one additional trial found inconsistent effects associated with glass ionomer sealants vs. no sealants on dental caries.¹

In a single trial (n=452)²⁰ of children with high baseline dental caries burden and suboptimal fluoridation, SDF administered by dental professionals was associated with fewer new surfaces with active caries in primary teeth (mean, 0.3 vs. 1.4; p<0.001) and first permanent molars (mean, 0.4 vs. 1.1; p<0.001) and decreased likelihood of new decayed or filled teeth (26.1% vs. 49.7%; relative risk, 0.52 [95% CI, 0.40 to 0.70]).^1,20 Training approaches for dental professionals were not reported.¹

The review identified 10 trials (n=4,267) evaluating xylitol in children age 5 years or older.¹ In two fair-quality trials, xylitol was administered under supervision at school with no benefit, or the results varied by control.¹ In one trial (n=496) of children with low baseline dental caries burden, xylitol (vs. no xylitol) was associated with no group differences in DMFS increment at 4 years (mean, 2.75 for xylitol for 1 year vs. 3.02 for 2 years vs. 2.74 for no xylitol; p>0.05).¹ A second fair-quality trial (n=432) of children with high baseline dental caries burden also found no difference between xylitol vs. placebo in DMFS increment at 3 years (mean, 8.1 vs. 8.3; p>0.05) and decreased DMFS increment in the xylitol group vs. no xylitol (mean increment, 8.1 vs. 12.4; p<0.05).¹ In eight other trials (effective n=1,646), xylitol was associated with some benefit, but studies were of poor quality with significant methodological limitations (e.g., unclear randomization, allocation, or concealment).¹

Harms of Preventive Interventions

The review found very limited evidence on the harms of interventions, including a lack of evidence on exposure to oral fluoride supplements in children and adolescents ages 5 to 17 years. Often, identified studies did not report any harms.

A single trial (n=349)²¹ reported no adverse events of fluoride supplements; other trials did not report harms.¹ Two trials (n=490) found no association between use of fluoride gels and nausea, gagging, and vomiting (absolute risk difference, 0.01 [95% CI, -0.01 to 0.02]; I²=0%).¹ A single trial reported self-limited adverse events (nausea) in 12 of 1,473 children using fluoride varnish; four trials did not report harms.¹ In a systematic review of resin-based sealants, three trials (n=775) reported no harms and 13 trials did not report harms.¹ A trial on glass ionomer sealants did not report harms.¹ A single trial (n=452) reported that SDF was associated with black staining on inactive dental caries in primary teeth (97% vs. 48%; p<0.001) and in first permanent molars (86% vs. 67%; p<0.001).¹ Studies reported that SDF treatment commonly results in black staining of carious lesions.^1,22 A single trial of xylitol (n=296) reported one participant withdrawal due to diarrhea; nine trials did not report harms.¹

See Table 2 for research needs and gaps related to screening and preventive interventions for oral health in adults.

The U.S. Department of Health and Human Services’ Report of the Surgeon General (2000) and the National Institutes of Health’s update (2020) emphasize the importance of integrating oral health into primary care medical settings, primarily focusing on counseling, coordination, and referral.^2,3

The National Academy of Medicine’s (formerly the Institute of Medicine) and the Health Resources and Services Administration’s report Advancing Oral Health in America (2011) recommends strategic action for prioritization of oral health within U.S. Department of Health and Human Services agencies and in its partnerships with other stakeholders.⁴

The American Academy of Pediatrics (AAP) recommends that pediatricians perform oral health risk assessments on all children at every routine well-child visit beginning at age 6 months. The AAP also recommends fluoride varnish application according to the AAP/Bright Futures periodicity schedule (applied at least once every 6 months for all children and every 3 months for children at high risk for dental caries) and dietary fluoride supplements for all children who do not have an adequate supply of fluoride in their primary drinking water.²³

The American Dental Association and American Academy of Pediatric Dentistry have issued guidelines on oral health (e.g., oral health education, sealants, prevention of dental caries, fluoride supplementation, and prevention of periodontitis) aimed at dental professionals.^24,25 The American Academy of Family Physicians recommends 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 starting at primary tooth eruption.^26,27 Guidelines from all three organizations generally recommend counseling and use of topical fluoride, dietary fluoride supplementation in settings with inadequate water fluoridation, and dental sealants as preventive measures in children and adolescents.^24-27

Abbreviation: USPSTF=U.S. Preventive Services Task Force.

To fulfill its mission to improve health by making evidence-based recommendations for preventive services, the USPSTF routinely highlights the most critical evidence gaps for making actionable preventive services recommendations. The USPSTF often needs additional evidence to create the strongest recommendations for everyone and especially for persons with the greatest burden of disease. In Table 2, the USPSTF summarizes the key bodies of evidence needed for the USPSTF to make recommendations for screening and preventive interventions for oral health in children ages 5 to 17 years. For each of the evidence gaps listed below, research must focus on screening and preventive interventions that can be performed in primary care settings and be inclusive of populations with a high prevalence of oral health conditions, including Black, Hispanic/Latino, Asian, Native American/Alaska Native, and Native Hawaiian/Pacific Islander persons and persons with social determinants that contribute to disparities in oral health.