Draft Recommendation Statement
Oral Health in Adults: Screening and Preventive Interventions
May 23, 2023
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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- Update in Progress for Oral Health in Adults: Screening and Preventive Interventions
- Update in Progress for Oral Health in Children and Adolescents Ages 5 to 17 Years: Screening and Preventive Interventions
|Asymptomatic adults age 18 years or older||The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults.||I|
|Asymptomatic adults age 18 years or older||The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults.||I|
- Draft Evidence Review (May 23, 2023)
- Final Research Plan (June 24, 2021)
- Draft Research Plan (March 18, 2021)
- Screening and Preventive Interventions for Oral Health in Children 5 Years and Older and Adults (Consumer Guide): Draft Recommendation | Link to File New Resource for Clinicians and Patients
|Table of Contents||PDF Version and JAMA Link||Archived Versions|
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.
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 Dental caries (cavities) and periodontal disease (gum disease) are common and often untreated oral health conditions that affect eating, speaking, learning, smiling, and employment potential.1-4 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).1,2,4 Dental caries and periodontitis disproportionately affect persons living in poverty; Black, Hispanic/Latino, Native American/Alaska Native, adults; adults with special needs; older adults; adults living in rural and urban underserved areas; adults without insurance or with public insurance; and adults experiencing homelessness.1,2 Untreated oral health conditions can lead to tooth loss, irreversible tooth damage, and other serious adverse health outcomes.1,5
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 or periodontal disease) performed by primary care clinicians in asymptomatic adults.
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 or periodontal disease) performed by primary care clinicians in asymptomatic adults.
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.6
Patient Population Under Consideration
This recommendation applies to asymptomatic adults age 18 years or older.
Dental caries refers to a multifactorial disease process resulting in demineralization of the teeth.7,8 Periodontal disease refers to inflammation of the gingival tissue, or gingivitis, which affects the hard and soft tissue that support the teeth and can progress to periodontitis involving bone loss.1,9 Oral health conditions for this recommendation statement refer to clinical health outcomes focused on the presence and severity of dental caries, dental caries burden (number of affected teeth), presence and severity of periodontal disease, tooth loss, and morbidity, quality of life, functional status, and harms of screening and treatment related to these conditions.1 The USPSTF focused on dental caries and periodontitis as the most common oral health conditions and the most potentially amenable to primary care interventions.
Screening Tests and Interventions
Screening could include clinical assessments (e.g., physical examination) and risk prediction tools to identify adults at increased risk for dental caries or periodontal disease or adults who might most benefit from interventions to prevent dental caries or periodontal disease.1
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),1,10 and xylitol.1
Suggestions for Practice Regarding the I Statement
In deciding whether to routinely screen or deliver interventions for oral health conditions, primary care clinicians should consider the following.
Potential Preventable Burden
Dental caries are the most common condition in adults worldwide; over 90% of U.S. adults are affected by dental caries, and an estimated 26% have untreated dental caries.1,2 Untreated dental caries can lead to serious infections and tooth loss.1,8 An estimated 42% of U.S. adults older than age 30 years have periodontal disease, increasing to nearly 60% at age 65 years or older.1,11 Untreated periodontitis can contribute to destruction of tissues that support the teeth and is the leading cause of tooth loss in older adults.1,9,12,13
Older adults are more likely to have medical conditions or use medications causing xerostomia (dry mouth) that contribute to oral health conditions.1,14 Frequent intake of dietary sugars in foods and beverages, suboptimal fluoride exposure, oral hygiene practices (e.g., lack of tooth brushing and flossing), tobacco use, unhealthy alcohol use, and methamphetamine use increase the risk of oral health conditions.1 According to 2009 to 2016 National Health and Nutrition Examination Survey data, smokers have higher incidence of periodontal disease (62%) compared with adults age 30 years or older overall (42%).1,11
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, affecting access to dental care.1 For older adults, physical limitations and loss of dental coverage upon retirement can increase barriers to dental care.5
Potential screening approaches in primary care (e.g., oral clinical assessments or standardized risk assessment instruments) to identify persons with early untreated dental caries or periodontal disease or persons at increased future risk are noninvasive and would seem unlikely to cause serious harms, but evidence is lacking. Health education and counseling to encourage routine oral hygiene and reduce modifiable risk factors (e.g., frequent intake of refined sugars or tobacco use) are also noninvasive.
The USPSTF found little evidence on current practices in primary care for routine screening or performing interventions to prevent dental caries or periodontitis in adults. There are well-known significant barriers to providing oral health services in the primary care setting, including variable clinician access and familiarity with interventions.1 Primary care clinicians may need additional training and specific equipment to deliver screening and interventions, have reimbursement challenges, and encounter 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 years after tooth eruption.15 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).
Other Related USPSTF Recommendations
The USPSTF has issued recommendations on screening and interventions to prevent dental caries in children younger than age 5 years,15 screening for oral cancer,16 interventions for tobacco smoking cessation in adults, including pregnant persons,17 and screening and preventive interventions for oral health in children and adolescents ages 5 to 17 years (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 adults. The USPSTF previously addressed counseling to prevent dental and periodontal disease (1996). Concurrently, the USPSTF commissioned a systematic evidence review to evaluate the benefits and harms of oral health screening and preventive interventions in children and adolescents ages 5 to 17 years;18 this recommendation is addressed in a separate statement.
Accuracy of Screening Tests
The USPSTF found limited evidence on diagnostic accuracy to identify adults with oral health conditions in the primary care setting. The review identified six studies (n=1,281) of self-reported questionnaires on perceived dental health designed to distinguish between persons with and without periodontitis, but most questionnaires included history of periodontitis, making them less relevant for screening.1 The questionnaires demonstrated fair discrimination (area under summary receiver operating characteristic, 0.79 [95% CI, 0.75 to 0.83]).1 The evidence review did not identify any questionnaires designed to identify adults with dental caries.
The single primary care study19 (n=86) evaluating the accuracy of clinical examination to identify dental caries found high specificity for dental caries and periodontitis (range, 0.80 to 0.93) but low sensitivity for periodontitis (0.56 [95% CI, 0.38 to 0.74] and 0.42 [95% CI, 0.24 to 0.56] for two examiners) and variable sensitivity for dental caries (0.33 [95% CI, 0.12 to 0.62] and 0.83 [95% CI, 0.52 to 0.96]).1
The review found no evidence on diagnostic accuracy to identify adults at increased risk of future oral health outcomes.
Effectiveness of Screening
For evidence on whether screening prevented negative oral health outcomes in adults in the primary care setting, the review identified a single study in pregnant persons20 (n=427) that compared no screening with a dental screening approach involving two questions and an optional oral cavity visual inspection by midwives; there were no statistically significant group differences in number of decayed teeth or filled teeth, and measures of periodontitis and birth outcomes in both groups were similar.1,20
Harms of Screening
The same single study20 (n=427) evaluating screening vs. no screening in pregnant persons did not report examining harms of screening.1
Effectiveness of Preventive Interventions
The USPSTF sought evidence of interventions implemented in a primary care setting that could prevent a broad collection of oral health conditions; however, the evidence review 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 in a primary care setting to prevent oral health outcomes but found no such evidence.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. The review did not find evidence evaluating the effects of interventions on nonoral health outcomes such as cardiovascular or cognitive outcomes, quality of life, or functional status.1
The review found no evidence on fluoride interventions provided by primary care clinicians. Five trials (n=971) in adults reported on the effects of topical fluorides (varnish or gel/solution) applied by dental professionals to prevent dental caries.1 In the single randomized clinical trial21 (n=104) of older adults in residential and nursing homes, application of fluoride varnish (sodium fluoride 22,600 ppm) every 3 months was associated with a nonstatistically significant reduction in dental caries at 1 year (mean difference in new active dental caries or fillings, 0.7; p>0.05), but at 2 and 3 years, group differences were statistically significant (mean difference, 1.8; p<0.001 and mean difference, 1.6; p<0.001, respectively).1 In addition, fluoride varnish was associated with decreased risk of developing new dental caries (relative risk, 0.25 [95% CI, 0.10 to 0.63]), translating to a number needed to treat of 3.1 (95% CI, 2.1 to 7.7).1 A nonrandomized cluster trial22 (n=232) of older adults in long-term care facilities found no group differences in dental caries burden (based on DMFT [Decayed, Missing, and Filled Teeth/Decayed, Filled Teeth] score) at 1 year (adjusted mean difference, -0.04 [95% CI, -0.10 to 0.03]).1 The three additional trials of other topical fluorides approaches (sodium fluoride 2% solution, stannous fluoride [30%] paste followed by aqueous solution, and acidulated phosphate fluoride [1.2%] at varied time frames) obtained inconsistent results.1
Sealants, SDF, and Xylitol
The review found no studies on the effectiveness of sealants vs. no sealants to prevent dental caries in primary care. Two trials (n=178) evaluating light-cured resin-based sealants in young adults applied by dental professionals were of limited quality and yielded imprecise results.1 Three trials (n=744) examined the effectiveness of SDF to reduce dental caries or filings in older adults.1 Fluoride exposure (i.e., oral health behaviors) was reported in one study and not reported in two studies.1 In older adults, evidence suggests that SDF may be more effective than placebo to reduce new root dental caries or fillings (mean difference, -0.33 to -1.3 at 24 to 30 months).1 SDF may also reduce likelihood of developing new root dental caries (adjusted odds ratio, 0.4 [95% CI, 0.3 to 0.7] and relative risk, 0.19 [95% CI, 0.07 to 0.46] in two randomized clinical trials; n=478).1 No evidence was found evaluating the effects of xylitol to prevent dental caries or periodontitis.1
Harms of Preventive Interventions
The review found very limited evidence on the harms of interventions. Of the nine studies reviewed assessing preventive interventions, one trial evaluating fluoride varnish or SDF (vs. placebo) stated “no major side effects or discomfort was reported.”1,21 Eight other trials did not report examining for harms.1
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.2,14 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.5
The American Dental Association (2013) recommends professionally applied 2.26% fluoride varnish or 1.23% fluoride gel in adults at elevated risk of developing dental caries.23 The American Academy of Family Physicians (2018) recommends that primary care clinicians educate patients about risks and benefits of fluoride; it recommends dietary fluoride supplements for children age 6 months through 16 years in areas where fluoride drinking water levels are suboptimal.24 The American College of Obstetricians and Gynecologists (2013) recommends routine counseling about the importance of oral health care during pregnancy and maintaining good oral health habits throughout the lifespan.25
See Table 2 for research needs and gaps related to screening and preventive interventions for oral health in adults.
1. Chou R, Selph S, Bougatsos C, et al. Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No 233. Rockville, MD: Agency for Healthcare Research and Quality; 2023. AHRQ Publication No. 23-05305-EF-1.
2. National Institutes of Health. Oral Health in America: Advances and Challenges. Accessed April 19, 2023. https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf
3. Centers for Disease Control and Prevention. Oral Health Fast Facts. Accessed April 19, 2023. https://www.cdc.gov/oralhealth/fast-facts/index.html
4. Agency for Healthcare Research and Quality. 2022 National Healthcare Quality and Disparities Report. Accessed April 19, 2023. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr22/index.html
5. Institute of Medicine. Advancing Oral Health in America. Washington, DC: National Academies Press; 2011.
6. U.S. Preventive Services Task Force. Procedure Manual. Accessed April 19, 2023. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual
7. Pitts NB, Zero DT, Marsh PD, et al. Dental caries. Nat Rev Dis Primers. 2017;3(1):17030.
8. Caufield PW, Griffen AL. Dental caries. An infectious and transmissible disease. Pediatr Clin North Am. 2000;47(5):1001-1019.
9. Centers for Disease Control and Prevention. Gum Disease. Accessed April 19, 2023. https://www.cdc.gov/oralhealth/fast-facts/gum-disease/index.html
10. Ruff RR, Barry-Godín T, Niederman R. Effect of silver diamine fluoride on caries arrest and prevention: the CariedAway school-based randomized clinical trial. JAMA Netw Open. 2023;6(2):e2255458.
11. Eke PI, Thornton-Evans GO, Wei L, Borgnakke WS, Dye BA, Genco RJ. Periodontitis in US adults: National Health and Nutrition Examination Survey 2009-2014. J Am Dent Assoc. 2018;149(7):576-588.e6.
12. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Accessed April 19, 2023. https://www.cdc.gov/oralhealth/publications/OHSR-2019-index.html
13. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res. 2012;91(10):914-920.
14. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Accessed April 19, 2023. https://www.nidcr.nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
15. US Preventive Services Task Force. Screening and interventions to prevent dental caries in children younger than 5 years: US Preventive Services Task Force recommendation statement. JAMA. 2021;326(21):2172-2178.
16. US Preventive Services Task Force. Screening for oral cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(1):55-60.
17. US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265-279.
18. Chou R, Bougatsos C, Griffin J, et al. Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Children and Adolescents Ages 5 to 17 Years: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No 232. Rockville, MD: Agency for Healthcare Research and Quality; 2023. AHRQ Publication No. 23-05304-EF-1.
19. Westman EC, Duffy MB, Simel DL. Should physicians screen for oral disease? J Gen Intern Med. 1994;9(10):558-562.
20. George A, Dahlen HG, Blinkhorn A, et al. Evaluation of a midwifery initiated oral health-dental service program to improve oral health and birth outcomes for pregnant women: a multi-centre randomised controlled trial. Int J Nurs Stud. 2018;82:49-57.
21. Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. J Dent Res. 2010;89(10):1086-1090.
22. Jabir E, McGrade C, Quinn G, et al. Evaluating the effectiveness of fluoride varnish in preventing caries amongst long-term care facility residents. Gerodontology. 2022;39(3):250-256.
23. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride for caries prevention. J Am Dent Assoc. 2013;144(11):1279-1291.
24. American Academy of Family Physicians. Oral Health. Accessed April 19, 2023. https://www.aafp.org/about/policies/all/oral-health.html
25. American College of Obstetricians and Gynecologists. Committee Opinion No. 569: Oral Health Care During Pregnancy and Throughout the Lifespan. Accessed April 19, 2023. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/08/oral-health-care-during-pregnancy-and-through-the-lifespan
|Detection||Inadequate evidence about the accuracy of screening for oral health performed by primary care clinicians in identifying asymptomatic adults who have or are at increased risk for oral health conditions (e.g., dental caries or periodontal disease).|
|Benefits of early detection and preventive interventions||
|Harms of early detection and preventive interventions||
Abbreviation: 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. Table 2 summarizes the key bodies of evidence needed for the USPSTF to make recommendations for screening and preventive interventions for oral health in adults. 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 Hawaiian Native/Pacific Islander persons and persons with social determinants that contribute to disparities in oral health.
|Screening for Oral Health in Adults|
|Research is needed to assess the effectiveness and harms of primary care–based oral health screening strategies on oral health outcomes.|
|Research is needed on the diagnostic accuracy of oral health examinations and risk assessment tools in the primary care setting to identify adults with oral health conditions.|
|Preventive Interventions for Oral Health in Adults|
|Research is needed to develop primary care–based oral health risk assessment tools to accurately identify adults at increased risk of oral health conditions.|
|Research is needed to assess the effectiveness and harms of preventive interventions in the primary care setting.
|Research is needed to identify the effectiveness of strategies to prevent periodontitis that can be delivered in primary care settings and their effects on potentially associated adverse health outcomes such as tooth loss or cognitive or cardiovascular conditions.|