DOI: 10.1542/peds.2014-0483; originally published online May 5, 2014; 2014;133;1102Pediatrics

Virginia A. MoyerPreventive Services Task Force Recommendation Statement

Prevention of Dental Caries in Children From Birth Through Age 5 Years: US  

  http://pediatrics.aappublications.org/content/133/6/1102.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Prevention of Dental Caries in Children From BirthThrough Age 5 Years: US Preventive Services Task ForceRecommendation Statement

abstractDESCRIPTION: Update of the 2004 US Preventive Services Task Force(USPSTF) recommendation on prevention of dental caries in preschool-aged children.

METHODS: The USPSTF reviewed the evidence on prevention of dentalcaries by primary care clinicians in children 5 years and younger, fo-cusing on screening for caries, assessment of risk for future caries,and the effectiveness of various interventions that have possible ben-efits in preventing caries.

POPULATION: This recommendation applies to children age 5 yearsand younger.

RECOMMENDATION: The USPSTF recommends that primary care clini-cians prescribe oral fluoride supplementation starting at age 6 monthsfor children whose water supply is deficient in fluoride. (B recommen-dation) The USPSTF recommends that primary care clinicians applyfluoride varnish to the primary teeth of all infants and children startingat the age of primary tooth eruption. (B recommendation) The USPSTFconcludes that the current evidence is insufficient to assess the bal-ance of benefits and harms of routine screening examinations for den-tal caries performed by primary care clinicians in children from birthto age 5 years. (I Statement) Pediatrics 2014;133:1102–1111

AUTHORS: Virginia A. Moyer, MD, MPH, on behalf of the USPreventive Services Task Force

KEY WORDSdentistry/oral health, preventive medicine

ABBREVIATIONSAAP—American Academy of PediatricsADA—American Dental AssociationNHANES—National Health and Nutrition Examination SurveyUSPSTF—US Preventive Services Task Force

Recommendations made by the US Preventive Services TaskForce are independent of the US government. They should not beconstrued as an official position of the Agency for HealthcareResearch and Quality or the US Department of Health andHuman Services.

The US Preventive Services Task Force (USPSTF) makesrecommendations about the effectiveness of specific preventivecare services for patients without related signs or symptoms.

It bases its recommendations on the evidence of both thebenefits and harms of the service and an assessment of thebalance. The USPSTF does not consider the costs of providinga service in this assessment.

The USPSTF recognizes that clinical decisions involve moreconsiderations than evidence alone. Clinicians shouldunderstand the evidence but individualize decision making tothe specific patient or situation. Similarly, the USPSTF notes thatpolicy and coverage decisions involve considerations in additionto the evidence of clinical benefits and harms.

For a list of the USPSTF members, see the Appendix.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-0483

doi:10.1542/peds.2014-0483

Accepted for publication Feb 19, 2014

Address correspondence to USPSTF Coordinator, Agency forHealthcare Research and Quality, 540 Gaither Rd, Rockville, MD20850. E-mail: coordinator@uspstf.net.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: The US Preventive Services Task Force is anindependent, voluntary body. The US Congress mandates thatthe Agency for Healthcare Research and Quality support theoperations of the US Preventive Services Task Force.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

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SUMMARY OF RECOMMENDATIONSAND EVIDENCE

TheUSPreventive Services Task (USPSTF)recommendsthatprimarycarecliniciansprescribe oral fluoride supplementationstarting at age 6 months for childrenwhose water supply is deficient in fluo-ride. (B recommendation)

The USPSTF recommends that pri-mary care clinicians apply fluoridevarnish to the primary teeth of allinfants and children starting at theage of primary tooth eruption. (Brecommendation)

See the Clinical Considerations sectionfor additional information on thesepreventive interventions.

The USPSTF concludes that the currentevidence is insufficient to assess the

balance of benefits and harms of rou-tine screening examinations for dentalcaries performed by primary careclinicians in children from birth to age5 years. (I Statement)

See the Clinical Considerations sectionfor suggestions for practice regardingthe I statement.

The target audience for USPSTF rec-ommendations is primary care clini-cians, who provide a wide range ofhealth care services to individuals. Al-though dentists can be consideredprimary care providers of oral healthneeds, for the purposes of this rec-ommendation statement, a primarycare clinician or primary care pro-vider is defined as a nondental healthcare professional (eg, physician, nursepractitioner).

RATIONALE

Importance

Dental caries is the most commonchronicdisease inchildren in theUnitedStates.1 According to the 1999–2004National Health and Nutrition Exami-nation Survey (NHANES), ∼42% of chil-dren ages 2 to 11 years have dentalcaries in their primary teeth. After de-creasing from the early 1970s to themid-1990s, the prevalence of dentalcaries in children has been increasing,particularly in young children ages 2to 5 years.2

Recognition of Risk Status

Risk assessment tools generally eval-uate risk based on factors such asdemographic risk, personal and family

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oral health history, dietary habits,fluoride exposure, and oral hygienepractices. Information from a clinicalevaluation also has been proposed,as well as qualitative or quantitativemeasure of oral bacterial load. TheUSPSTF found no studies that evaluatedthe accuracy of risk assessmentinstruments for future dental caries inthe primary care setting.

Benefits of PreventiveInterventions and Early Detection

Preventive Interventions

The USPSTF found adequate evidencethatoralfluoridesupplementation, alsoknown as dietary fluoride supplemen-tation, in childrenwhohave low levels offluoride in their water and applicationof fluoride varnish to the primary teethof all children can each providemoderate benefit in preventing den-tal caries.

The USPSTF found insufficient evidenceon the benefits of provider education ofparents regarding oral hygiene prac-tices to prevent dental caries in theirchildren.

Screening

The USPSTF found no studies address-ing the direct effect of routine oralscreening examinations performed byprimary care clinicians on improvedclinical outcomes in children youngerthan 5 years.

Harms of Preventive Interventionsand Early Detection

Preventive Interventions

The USPSTF found adequate evidence ofa link between early childhood expo-sure to systemic fluoride and enamelfluorosis, a visible change in the ap-pearance of the enamel due to alteredmineralization. Fluorosis can rangefrom mild (small white spots orstreaks) to severe (discoloration, pit-ting, or rough enamel), depending on

the overall systemic fluoride exposurelevel over time.

No studies specifically reported on therisk for fluorosis with fluoride varnish;however, compared with other topicalfluoride interventions, systematic ex-posure to fluoride is low after varnishapplication.3,4 It is important to con-sider a child’s overall systemic expo-sure to fluoride from multiple sources(eg, water fluoridation, toothpaste,supplements, and/or varnish), but inthe United States, enamel fluorosispresents as mild cosmetic changes in.99% of cases.5

The USPSTF concludes that there islimited evidence about the harms as-sociated with fluoride varnish or otherpreventive interventions for dentalcaries, but that these risks are likelysmall.

Screening

TheUSPSTF foundnostudies addressingthe magnitude of harms of screeningchildren from birth to age 5 years fordental caries or future risk for dentalcaries in the primary care setting.

USPSTF Assessment

The USPSTF concludes with moderatecertainty that there is a moderate netbenefit of preventing future dentalcaries with oral fluoride supplemen-tation at recommended doses in chil-dren older than 6 months who residein communities with inadequate waterfluoride.

The USPSTF concludes with moderatecertainty that there is a moderate netbenefit of preventing future dentalcaries with fluoride varnish applica-tion in all children starting at the ageof eruption of primary teeth to age5 years.

The USPSTF concludes that the evi-dence on performing routine oralscreening examinations for dental car-ies in children from birth to age 5 years

is insufficient, and the balance of ben-efits and harms of screening cannot bedetermined.

CLINICAL CONSIDERATIONS

Patient Population UnderConsideration

This recommendation applies to chil-dren age 5 years and younger.

The USPSTF limited its considerationof caries screening and prevention byprimary care clinicians to infants andpreschool-aged children. The rationalefor this decision was that, at thepresent time, nondental primary careclinicians aremore likely than dentiststo have contact with children ages5 years and younger in the UnitedStates6,7; this situation changes aschildren reach school age and beyond.In addition, as children grow older,dental professionals use sealantsrather than fluoride varnish. As such,the USPSTF limited its review of theevidence of preventive interventionsfor dental caries to this age group.This recommendation should not beconstrued to imply that preventiveinterventions for dental caries shouldcease after 5 years of age.

Assessment of Risk

All children are at potential risk fordental caries; those whose primarywater supply is deficient in fluoride(defined as containing,0.6 ppm F) areat particular risk. Although there areno validated multivariate screeningtools to determine which children areat higher risk for dental caries, thereare a number of individual factors thatelevate risk. Higher prevalence andseverity of dental caries are foundamong minority and economically dis-advantaged children. Other risk factorsfor caries in children include frequentsugar exposure, inappropriate bottlefeeding, developmental defects of thetooth enamel, dry mouth, and a history

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of previous caries. Maternal and familyfactors also can increase children’srisk. These factors include poor oralhygiene, low socioeconomic status,recent maternal caries, sibling caries,and frequent snacking. Additional fac-tors associated with dental caries inyoung children include lack of accessto dental care; inadequate preventivemeasures, such as failure to usefluoride-containing toothpastes; andlack of parental knowledge aboutoral health.8,9

Some organizations have advocatedrestricting fluoride varnish use tochildren at “increased risk.” Althoughseveral caries risk assessment toolsexist, none have been validated in theprimary care setting, nor do existingstudies demonstrate that these tools,when used by primary care clini-cians, can accurately and consis-tently differentiate between childrenwho will develop dental caries andthose who will not.8,9 A risk-basedapproach to fluoride varnish appli-cation will miss opportunities toprovide an effective dental cariespreventive intervention to childrenwho could benefit from it, particu-larly because currently, in the UnitedStates, infants and preschool-agedchildren are more likely to have reg-ular visits with nondental primarycare clinicians than dental care pro-viders.6,7

Interventions to Prevent DentalCaries

As noted previously, oral fluoride sup-plementation prevents dental caries inpatients with inadequate water fluori-dation.

All children with erupted teeth canpotentially benefit from the periodicapplication of fluoride varnish, re-gardless of the levels offluoride in theirwater. Although the evidence to supportvarnish is drawn from higher-riskpopulations, the provision of varnish

to all children is reasonable, as theprevalence of risk factors is high in theUS population, the number needed totreat is low, and the harms of the in-tervention are small to none.

The USPSTF did not review the evi-dence on the effectiveness of toothbrushing, but regular tooth brushingwith fluoride toothpaste by childrenis very important in preventing dentalcaries.10

Timing and Dosage of PreventiveInterventions

No studies specifically addressed thedosage and timing of oral fluoridesupplementation in children with in-adequate water fluoridation. TheAmerican Dental Association (ADA) rec-ommendations on the dosage of andage at which to start dietary fluoridesupplementation take into account theamount of fluoride in the child’s watersource.11 These dosing recommendationsalso are referenced by the AmericanAcademy of Pediatrics (AAP).12

No study directly assessed the appro-priate ages at which to start and stopthe application of fluoride varnish.Available trials of fluoride varnish en-rolled children ages 3 to 5 years;however, given themechanismof actionof this intervention, benefits are verylikely to accrue starting at the timeof primary tooth eruption. Limited evi-dence found no clear effect on cariesincrement betweenperforminga singlefluoride varnish once every 6 monthsversus once a year13 or between a sin-gle application every 6 months versusmultiple applications once a year orevery 6 months.14,15

Suggestions for Practice Regardingthe I Statement

In deciding whether to routinely per-formscreening examinations fordentalcaries in children from birth to age5 years, clinicians should consider thefollowing factors.

Potential Preventable Burden

Dental caries is the most commonchronicdisease inchildren in theUnitedStates. It is 4 times more common thanchildhood asthma and 7 times morecommon than hay fever. According tothe NHANES, the prevalence of dentalcaries has risen from 24% to 28% be-tween 1988–1994 and 1999–2004.2 Ap-proximately 20% of surveyed childrenwith caries had not received treatment.Symptomatic dental caries in childrenare associated with pain, loss of teeth,impaired growth, and decreased weightgain, and can affect appearance, self-esteem, speech, and school perfor-mance. Dental-related concerns lead tothe loss of more than 54 million schoolhours each year.16

Potential Harms

No studies examined the harms ofperforming primary care screeningexaminations for dental caries inchildren from birth to age 5 years.8,9

However, given the noninvasive natureof an oral examination, these harmsare expected to be minimal.

Current Practice

In one study, only about half of pedia-tricians reported examining the teethof half of their patients ages 0 to 3years.17

Other Approaches to Prevention

In April 2013, the Community PreventiveServices Task Force recommended fluo-ridation of community water sourcesbased on strong evidence of effective-ness in reducing dental caries.18 Italso recommends school-based dentalsealant delivery programs to preventcaries.

Xylitol may have promise as an addi-tional method to reduce the risk fordental caries. Xylitol is classified by theUS Food and Drug Administration asa dietary supplement and is found inover-the-counter consumer products,

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such as wipes or gum. A single small,fair-quality trial of xylitol wipes usein children ages 6 to 35 monthsfound a 91% relative reduction indecayed, missing, or filled surfaceincrement19; however, 4 other stud-ies showed no clear effect of xylitolon caries risk in children youngerthan 5 years.20–23 As such, there iscurrently not enough evidence toformally recommend its routine usein caries prevention.

OTHER CONSIDERATIONS

Implementation

Many primary care providers alreadyprescribe oralfluoride supplementationto patients with low levels of fluoridein their water; however, application offluoride varnish is not currently com-monly performed in many primarycare offices (estimated at about 4% ofpractices in 2009).17 The techniques forapplication are simple and easy tolearn, and fluoride varnish does notrequire specialized equipment or per-sonnel and can be applied quickly.However, providers and other qualifiedstaff may require some training beforeoffering this procedure.24,25 Dentistsand physicians can apply varnish inall states. In some states, physicianassistants, nurse practitioners, nurses,and medical assistants can do so also.

Efforts are under way to address con-cerns surrounding resources, in-frastructure, training, and paymentmechanisms for the provision of fluo-ride varnish in the nondental primarycare setting. For example, the AAPSection on Oral Health has partneredwith the Health Resources and ServicesAdministration’s Maternal and ChildHealth Bureau and the ADA Foundationto educate and advocate for primarypediatric care professionals to applyfluoride varnish. They have createda Web site with a number of helpfultools and resources to assist nondentalprimary care providers, including how

to acquire the materials required to pro-vide varnish, as well as state-by-state in-formation on billing codes and anytraining requirements (available at http://www2.aap.org/oralhealth/PracticeTools.html). The National InterprofessionalInitiative on Oral Health, a consortiumof funders and health professionals,focuses on educating and training pri-mary care clinicians on oral healthprevention (additional information isavailable at http://www.niioh.org).

Cost

State Medicaid reimbursement forfluoride varnish application, when of-fered, ranges from $9 to $53 per ap-plication when applied by licensedproviders who have had appropriatetraining, including physicians, physi-cian assistants, nurse practitioners,registered nurses, and licensed prac-tical nurses (varying by state).26

Research Needs and Gaps

Studies are needed to assess and val-idate multivariate risk assessmenttools that can accurately identify high-risk populations most likely to benefitfrom caries preventive interventions,such as fluoride varnish.

Further research also would be helpfulto confirm the benefits of fluoridevarnish among lower-risk and youngerchildren.

Racial and ethnic minority children, aswell as children living in low socioeco-nomic conditions, are at significantly in-creased risk for caries compared withwhite children and children who livein adequate to high socioeconomic con-ditions. Future studies on risk assess-mentandpreventive interventionsshouldenroll sufficient numbers of racial andethnic minority children to understandthe benefits and harms of interventionsin these specific populations.

More research also is needed to esti-mate the effectiveness of interventionsby clinicians to educate parents and

caregivers about optimum health prac-tices for oral hygiene at home.

DISCUSSION

Burden of Disease

Dental caries is the most commonchronicdisease inchildren in theUnitedStates, and is increasing in prevalenceamong young children.1 According tothe NHANES, the prevalence of toothdecay in primary teeth in children ages2 to 5 years increased from approxi-mately 24% to 28% between 1988–1994and 1999–2004.2 Approximately 20% ofsurveyed children with caries had notreceived treatment of the condition.

In addition, the NHANES found thatamong children ages 2 to 11 years, 54%of children in households living belowthe federal poverty threshold had pri-mary dental caries, as well as one-thirdof children in households living 200%above the poverty threshold. Fifty-fivepercent of Mexican American childrenhave dental caries compared with 43%of African American children and 39%of white children. Mexican Americanchildren also are more likely to haveuntreated dental caries (33%) thanAfricanAmerican (28%)andwhite (20%)children.2

Early childhood caries can cause pain,loss of teeth, caries later in life, im-paired growth/weight gain, missedschool days, and negative effects onquality of life. Caries in early childhoodare associated with failure to thriveand can affect speech, appearance,and school performance. They arealso associated with an increased riskfor caries in additional primary orpermanent teeth. More than 51 millionhours of school are missed eachyear because of childhood dentalconcerns.16

Scope of Review

To update the 2004 recommendation,the USPSTF commissioned a systematic

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review of the evidence on prevention ofdental caries by primary care cliniciansin children 5 years and younger. Thereview focused on screening for caries,assessment of risk for future caries,and the effectiveness of various inter-ventions that have possible benefits inpreventing caries.

Risk Assessment

No studies assessed the effective-ness of the use of formal risk as-sessment tools by primary careclinicians in identifying children athighest risk for dental caries. Al-though there are tools available fromseveral professional organizationsfor use in the primary care setting, nostudies evaluated their performanceor use.

Effectiveness of PreventiveInterventions

Fluoride Supplementation

Six older studies27–32 assessed the ef-fectiveness of oral fluoride supple-mentation; the USPSTF found no newstudies since its previous 2004 review.Although the studies had some meth-odological limitations, such as lack ofadjustment for potential confounders,inadequate blinding, or unreportedattrition, and were fairly heteroge-neous, they support the conclusionthat oral fluoride supplementationleads to decreased dental caries inchildren 5 years and younger who haveinadequate fluoridation in their water.The single randomized trial (n = 140;fluoridation level ,0.1 ppm F) foundthat 0.25-mg fluoride drops or chewswere associated with decreased riskfor caries versus no fluoride supple-mentation in Taiwanese children age2 years at enrollment.31 Relative re-ductions ranged from 52% to 72% fordecayed, missing, and filled teeth andfrom 51% to 81% for decayed, missing,and filled tooth surfaces. Across all 6trials, relative reductions with fluoride

supplementation ranged from 32% to72% for decayed, missing, and filledteeth and from 38% to 81% for decayed,missing, and filled tooth surfaces ver-sus placebo (vitamin drops) or nosupplementation.8,9

Fluoride Varnish

Three recent good- and fair-qualitytrials assessed professionally appliedtopical fluoride varnish in children 5years and younger. The trials com-pared fluoride varnish applied every6 months with no fluoride varnish.One was conducted in rural CanadianNative populations without waterfluoridation and another was con-ducted in an Australian aboriginalcommunity with water fluoridationlevels of,0.6 ppm F for nearly 90% ofparticipants.33,34 The third trial en-rolled primarily Latino and Chineseunderserved children in an urban UScommunity with adequate water fluo-ridation.13 All 3 trials found that fluo-ride varnish was associated with adecreased risk for dental caries after2 years. Absolute mean reductions inthe number of affected tooth surfacesranged from 1.0 to 2.4.8,9

Three fair-quality studies evaluatedthe effect of frequency of fluoridevarnish application on caries out-comes.13–15 Two found that multiplefluoride varnish applications withina 2-week period were associated withno statistically significant differencesin caries incidence versus a 6-monthapplication schedule.14,15 One trialfound no statistically significant dif-ference in caries rates for once- versustwice-yearly varnish application.13 Theoptimum frequency of fluoride varnishapplication is not known.

Effectiveness of Screening

No studies examined the effectivenessof routine oral screening examinationsperformedbyprimary careclinicians inpreventing dental caries.8,9

Potential Harms of PreventiveInterventions

The USPSTF considered a recently up-dated systematic review on enamel fluo-rosis that includes 5 new studies thatwere not available for the 2004 recom-mendation.35 These observational stud-ies consistently found an associationbetween early childhood exposure tosystemic fluoride and enamel fluorosis.The evidence is limited in that measuresof early childhood fluoride exposurewere based on parental recall.8,9 Riskestimates ranged from an odds ratio of10.8 (95% confidence interval 1.9–62.0)for exposure during the first 2 yearsof life to a slight increase in risk (oddsratio, 1.1–1.7, depending on compari-son).35 Fluorosis can range from mild(small white spots or streaks) to severe(discoloration, pitting, or brown stain-ing), depending on the overall systemicfluoride exposure level over time. In theUnited States, the prevalence of severeenamel fluorosis is estimated at,1%.5

No studies reported the risk for fluo-rosis with fluoride varnish application;however, the degree of systemic fluo-ride exposure after varnish applicationis low.3,4

Potential Harms of Screening

No studies compared harms in chil-dren who were receiving routine oralscreening examinations versus thosenot screened for dental caries by pri-mary care providers.8,9

Estimate of Magnitude of NetBenefit

The USPSTF concludes with moderatecertainty that there is a moderate netbenefit to prescribing oral fluoridesupplementationat recommendeddosesstarting at age 6 months to childrenwith inadequatefluoride in theirwater.

There is also moderate net benefit toapplyingfluoridevarnish to theprimaryteeth of all infants and children startingat the age of primary tooth eruption.

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The USPSTF found inadequate evidenceon the effectiveness of routine cariesscreening examinations performedby primary care providers to improveoutcomes in children 5 years andyounger. The USPSTF also found in-adequate evidence regarding the po-tential harms.

Therefore, the USPSTF concludes thatthe evidence on the benefits andharmsof routine caries screening examina-tions performed by primary careproviders in children 5 years andyounger is lacking, and the balanceof benefits and harms cannot be de-termined.

How Does Evidence Fit With BiologicUnderstanding?

Systemic fluoride becomes incorporatedinto tooth structures during their for-mation. If fluoride is ingested repeatedlyduring tooth development, it is de-posited throughout the tooth surfaceand provides protection against car-ies. Topical fluoride treatments, suchas varnishes, help protect teeth thatare already present. In this method,fluoride is incorporated into the sur-face layer of the teeth, making themmore resistant to decay. Systemicfluoride also provides some measureof topical effects, as it is found in thesaliva and bathes the teeth. Thus,providing both systemic and topicalfluoride to children during tooth de-velopment fits with the biologic un-derstanding of fluoride’s protectiveactions against dental decay.36,37

Response to Public Comments

A draft version of this recommendationstatement was posted for public com-ment on the USPSTF Web site fromMay 21 to June 20, 2013. All commentsreceived were reviewed during thecreation of the final recommendationstatement. Based on public feedback,the USPSTF separated its recommen-dationonfluoride supplementationand

the application of fluoride varnish into2 parts to increase clarity surroundingthe relevant populations for each in-tervention. The USPSTF expanded itsrationale for why it recommends fluo-ride varnish for all infants and childrenonce their primary teeth have erupted,rather than only those deemed to be at“high” risk, and why it believes that theavailable evidence was sufficient tomake this recommendation for non-dental primary care providers. TheUSPSTF added language concerningpotential implementation issues forthe use of fluoride varnish by primarycare professionals. The USPSTF alsoclarified the definitions of “primarycare provider,” “dental practitioner,”and “inadequate water fluoridation.”Finally, the USPSTF included an expla-nation of the target age range for thisrecommendation and provided addi-tional details on enamel fluorosis.

UPDATE OF PREVIOUSRECOMMENDATION

This is an update of the 2004 USPSTFrecommendation statement, in whichthe USPSTF recommended that primarycare clinicians prescribe oral fluoridesupplementation to children 6 monthsand older whose primary water sourceis deficient in fluoride (B recommenda-tion). This recommendation was basedon fair evidence that prescription oforal fluoride supplements by primarycare clinicians to young children withlow fluoride exposure is associatedwith reduced risk for dental cariesthat outweighs the potential harmsof enamel fluorosis, which primarilymanifests in the United States as mildcosmetic discoloration of the teeth.

The current statement similarly recom-mends oral fluoride supplementation,but expands to include the recommen-dation that primary care providers applyfluoride varnish to the primary teeth ofall children 5 years and younger startingat tooth eruption.

In 2004, the USPSTF concluded thatthe evidence was insufficient to rec-ommend for or against routine riskassessment by primary care cliniciansof children 5 years and younger for theprevention of dental disease (I state-ment). The current recommendationconcludes that there is not enoughevidence to recommend for or againstroutine oral screening examinationsfor dental caries performed by pri-mary careclinicians in children5yearsand younger.

RECOMMENDATIONS OF OTHERS

The AAP has issued 2 policy statementsrelated to dental care in children. Thefirst, issued in 2003 and reaffirmedin 2009, encourages providers to in-corporate oral health–related servicesinto their practices. Specifically, theAAP recommends an oral health as-sessment for all children by age 6months and a first dental visit by age1 year.38 The second statement sup-ports oral fluoride supplementationand application of fluoride varnish inchildren “at risk” for dental caries.39

The ADA recommends that children beseen by a dentist within 6 months oferuption of the first tooth and no laterthan age 12 months. It also recom-mends the application of fluoride var-nish every 6 months in preschool-agedchildren who are at moderate riskfor dental caries and every 3 to 6months in children who are at highrisk.40 It recommends daily dietaryfluoride supplements for childrenfrom birth to age 16 years who are athigh risk for developing dental cariesand whose primary source of drinkingwater is deficient in fluoride; high-riskstatus can be determined by usingrisk assessment tools developed by 1of several professional health organ-izations. Dietary fluoride supplemen-tation is not recommended whenwater fluoridation levels are .0.6ppm F.11

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The Centers for Disease Control andPrevention recommends that clinicianscounsel parents about appropriate useof fluoridated toothpastes, especially inchildren 2 years and younger; prescribefluoride supplements to children at highrisk for dental caries whose drinkingwater lacks adequate fluoridation; and

limit the use of high-concentrationfluoride products, such as varnish andgel, to high-risk individuals.37

The American Academy of Pediatric Den-tistry states that fluoride dietary supple-ments should be considered for childrenat risk for caries who drink fluoride-deficient (,0.6 ppm) water. It also

states that children at increased risk forcaries should receive a professionalfluoride treatment (eg, 5% sodium fluo-ride varnish or 1.23% acidulated phos-phate fluoride) every 6 months.41

The American Academy of FamilyPhysicians is updating its recom-mendations on the subject.

REFERENCES

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APPENDIX

US PREVENTIVE SERVICES TASKFORCE

Members of the USPSTF at the time thisrecommendation was finalized* areVirginia A. Moyer, MD, MPH, Chair(American Board of Pediatrics, ChapelHill, NC); Michael L. LeFevre, MD, MSPH,Co-Vice Chair (University of MissouriSchool of Medicine, Columbia, MO);Albert L. Siu, MD, MSPH, Co-Vice Chair

(Mount Sinai School of Medicine, NewYork, and James J. Peters VeteransAffairs Medical Center, Bronx, NY);Linda Ciofu Baumann, PhD, RN (Uni-versity of Wisconsin, Madison, WI);Susan J. Curry, PhD (University of IowaCollege of Public Health, Iowa City, IA);Mark Ebell, MD, MS (University ofGeorgia, Athens, GA); Francisco A.R.García, MD, MPH (Pima County Depart-ment of Health, Tucson, AZ); JessicaHerzstein, MD, MPH (Air Products,Allentown, PA); Douglas K. Owens, MD,

MS (Veterans Affairs Palo Alto HealthCare System, Palo Alto, and StanfordUniversity, Stanford, CA); William R.Phillips, MD, MPH (University ofWashington, Seattle, WA); and MichaelP. Pignone, MD, MPH (University ofNorth Carolina, Chapel Hill, NC).Former USPSTF members AdelitaGonzales Cantu, RN, PhD, David C.Grossman, MD, MPH, and GlennFlores, MD, also contributed to thedevelopment of this recommenda-tion.

*For a list of current Task Force members, go to www.uspreventiveservicestaskforce.org/members.htm.

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DOI: 10.1542/peds.2014-0483; originally published online May 5, 2014; 2014;133;1102Pediatrics

Virginia A. MoyerPreventive Services Task Force Recommendation Statement

Prevention of Dental Caries in Children From Birth Through Age 5 Years: US  

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