Draft Research Plan

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

March 18, 2021

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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The analytic framework depicts the relationship between the population, screening, interventions, outcomes, and potential harms of screening for oral health. The far left of the framework shows the target population for screening as children age 5 through 17 years at a clinician office visit. To the right of the population is an arrow corresponding to key question 2 which represents the accuracy of screening and risk factor assessment. This arrow leads to those at average or increased risk for oral health issues. This step may lead to harms, which corresponds to key question 3. Arrows show that children at either risk level may experience interventions with the aim of decreasing dental caries and tooth loss and improving quality of life, functional status, and morbidity. An overarching arrow representing key question 1 goes directly from screening to these outcomes of interest.

  1. How effective is screening for oral health performed by a primary care clinician in preventing negative oral health outcomes?
  2. How accurate is screening for oral health performed by a primary care clinician in identifying children and adolescents who:
    1. Have oral health issues?
    2. Are at increased risk of future oral health issues?
  3. What are the harms of screening for oral health performed by a primary care clinician?

The analytic framework depicts the relationship between the population, preventive interventions, outcomes and potential harms of interventions to prevent oral health issues. The far left of the framework describes the target population as children age 5 through 17 years at a clinician office visit. To the right of the population is an arrow corresponding to key question 1 which represents accuracy of risk factor assessment. This arrow leads to those at average or increased risk for oral health issues. Arrows show that children at either risk level would receive preventive interventions, as they are intended for those with without oral health issues. Key questions 2, 3, and 4 examine the effectiveness of behavioral counseling, referral to a dental health care provider, and preventive interventions, respectively, with the aim of decreasing dental caries and tooth loss and improving quality of life, functional status, and morbidity. Preventive interventions may lead to harms, which corresponds to an arrow for key question 5.

  1. How accurate is screening for oral health performed by a primary care clinician in identifying children and adolescents who are at increased risk of future oral health issues?*
  2. How effective is oral health behavioral counseling provided by a primary care clinician in preventing oral health issues?
  3. How effective is referral by a primary care clinician to a dental health care provider in preventing oral health issues?
  4. How effective are preventive interventions (e.g., flouride) in preventing oral health issues?
  5. What are the harms of specific interventions (behavioral counseling, referral, and preventive interventions) to prevent oral health issues?

*This is the same Key Question as 2b from the previous Analytic Framework.

The analytic framework depicts the relationship between the population, screening, interventions, outcomes, and potential harms of screening for oral health. The far left of the framework shows the target population for screening as adults >18 years of age at a clinician office visit. To the right of the population is an arrow corresponding to key question 2 which represents the accuracy of screening and risk factor assessment. This arrow leads to those at average or increased risk for oral health issues. This step may lead to harms, which corresponds to key question 3. Arrows show that adults at either risk level may experience interventions with the aim of decreasing dental caries, periodontal disease, and tooth loss and improving quality of life, functional status, and morbidity. An overarching arrow representing key question 1 goes directly from screening to these outcomes of interest.

  1. How effective is screening for oral health performed by a primary care clinician in preventing negative oral health outcomes?
  2. How accurate is screening for oral health performed by a primary care clinician in identifying adults who:
    1. Have oral health issues?
    2. Are at increased risk for future oral health issues?
  3. What are the harms of screening for oral health performed by a primary care clinician?

The analytic framework depicts the relationship between the population, preventive interventions, outcomes and potential harms of interventions to prevent oral health issues. The far left of the framework describes the target population as adults >18 years of age at a clinician office visit. To the right of the population is an arrow corresponding to key question 1 which represents accuracy of risk factor assessment. This arrow leads to those at average or increased risk for oral health issues. Arrows show that those at either risk level would receive preventive interventions, as they are intended for those with without oral health issues. Key questions 2, 3, and 4 examine the effectiveness of behavioral counseling, referral to a dental health care provider, and preventive interventions, respectively, with the aim of decreasing dental caries, periodontal disease, and tooth loss and improving quality of life, functional status, and morbidity. Preventive interventions may lead to harms, which corresponds to an arrow for key question 5.

  1. How accurate is screening performed by a primary care clinician in identifying adults who are at increased risk of future oral health issues?*
  2. How effective is oral health behavioral counseling provided by a primary care clinician in preventing oral health issues?
  3. How effective is referral by a primary care clinician to a dental health care provider in preventing oral health issues?
  4. How effective are preventive interventions (e.g., fluoride) in preventing oral health issues?
  5. What are the harms of specific interventions (behavioral counseling, referral, and preventive interventions) to prevent oral health issues?

*This is the same Key Question as 2b from the previous Analytic Framework.

Contextual questions will not be systematically reviewed and are not shown in the Analytic Framework. 

  1. What is the association between presence or severity of dental caries of deciduous or permanent teeth and pain, quality of life, function, and tooth loss/edentulism? What is the association between presence or burden of dental caries of deciduous teeth and subsequent presence or severity of dental caries of permanent teeth?
  2. What factors (e.g., race/ethnicity, age, socioeconomic status, cultural factors, educational attainment, or health literacy) are associated with oral health care disparities in children, adolescents, and adults?
  3. What is the effectiveness of primary care interventions to reduce oral health care disparities in children, adolescents, and adults?

The proposed Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the Key Questions.

This review will address screening, risk assessment, and preventive interventions for oral health in children (starting at age 5 years) through older adults. Younger children (younger than age 5 years) are addressed in a separate USPSTF recommendation. This review will focus on the oral health conditions of dental caries and periodontitis. Screening for oral cancer in adults is addressed in a separate USPSTF recommendation. Separate Analytic Frameworks address children and adolescents ages 5 to 17 years and adults. In addition, for each of these populations, separate Analytic Frameworks address screening for oral health conditions and prevention of oral health conditions, to more clearly distinguish treatment of children and adolescents with existing dental caries identified by screening (screening Analytic Framework) from treatment of children without dental caries to prevent the development of future caries (intervention Analytic Framework). Populations of interest include groups defined by age (for children, age <13 vs. ≥13 years [most children have 28 of their permanent teeth by age 13 years]; for adults, age <65 vs. ≥65 years), sex, socioeconomic status, race/ethnicity, educational attainment, and health literacy. Dental X-rays are not addressed because they are not typically obtained in primary care settings or ordered by primary care clinicians.

  Include Exclude
Populations Asymptomatic children (starting at age 5 years) through older adults, including pregnant persons

Populations of interest include groups defined by: age (children age <13 vs. ≥13 years; adults age <65 vs. ≥65 years), sex, socioeconomic status, race/ethnicity, educational attainment, and health literacy

 Children age <5 years (this population is addressed in a separate USPSTF recommendation)
Interventions Screening:
  • Oral examination/clinical assessment
  • Risk assessment for dental caries or periodontitis based on history, examination, standardized risk-assessment instrument, or some combination thereof

Preventive interventions:

  • Behavioral counseling/education
  • Preventive medications (topical fluoride [varnish, foam, or gel], oral fluoride supplementation [for children and adolescents], silver diamine fluoride, dental sealants, and xylitol-containing products)
  • Referral of persons deemed at high risk for oral diseases to a dental health care provider
 Treatment for existing oral health issues
Comparisons No intervention or placebo Active treatment
Outcomes Dental caries (incidence and severity)
Periodontal disease in adults (incidence and severity)
Tooth loss
Morbidity
Quality of life
Functional status
Harms of screening and treatment (e.g., dental fluorosis, tooth staining, bone effects, and neurological effects)		 Cost effectiveness
Setting Primary care or applicable to U.S. primary care practice (e.g., screening or preventive interventions do not require specialized dental training or equipment and are feasible for implementation in primary care); includes teledentistry approaches based in primary care settings Dental clinics providing interventions not available in primary care settings
Study Design Screening: Trials and cohort studies

Preventive interventions: Trials; large cohort studies for selected harms (e.g., dental fluorosis, harms related to radiation exposure)

Risk assessment: Studies of diagnostic accuracy or risk prediction		 Case-control studies or uncontrolled studies
Study Quality Good or fair quality Poor quality

Abbreviations: U.S. = United States; USPSTF = U.S. Preventive Services Task Force.