Oral Health in Adults: Screening and Preventive Interventions

The US 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 life span.^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 US, oral health disparities are shaped by inequities in the affordability and accessibility of dental care and other disadvantages related to social determinants of health (eg, living in an underserved rural area).^1,2,4 Dental caries and periodontitis disproportionately affect persons living in poverty; Asian, Black, Hispanic/Latino, Native American/Alaska Native, adults; adults with disabilities; adults 65 years or older or living in institutional settings; 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 (eg, 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 (eg, 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 aged 18 years or older.

Condition Definitions

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 supports 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

For the purposes of the review, screening included clinical assessments (eg, physical examination) and standardized risk prediction tools or a combination of approaches by primary care clinicians to identify adults who have existing oral health conditions or adults who might benefit most from interventions to prevent future negative oral health outcomes due to increased risk.¹ Interventions that were reviewed focused on preventing future dental caries and included 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 solution,^1,10 and xylitol.¹ The USPSTF found insufficient evidence to recommend for or against screening or preventive interventions for oral health conditions in the primary care setting for adults and suggests primary care clinicians use their clinical expertise to decide whether to perform these services.

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 is the most common condition in adults worldwide; more than 90% of US 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 US adults older than 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), which contributes to oral health conditions.^1,14 Frequent intake of dietary sugars in foods and beverages, suboptimal fluoride exposure, oral hygiene practices (eg, lack of toothbrushing and flossing), tobacco use, unhealthy alcohol use, and methamphetamine use increase the risk of oral health conditions.¹ According to 2009-2016 National Health and Nutrition Examination Survey data, people who smoke have a higher incidence of periodontal disease (62%) compared with adults 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 Harms

Potential screening approaches in primary care (eg, 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 (eg, frequent intake of refined sugars or tobacco use) are also noninvasive.

Current Practice

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. In its review of the evidence, the USPSTF found that preventive interventions are generally performed in dental settings by dental professionals. 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 preventive 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 starting at age 6 months for children younger than 5 years with water sources deficient in fluoride and administration of varnish to the primary teeth of all children younger than 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 US 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 US.

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 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 aged 5 to 17 years.¹⁸

Scope of Review

The USPSTF commissioned a systematic evidence review^1,19 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 aged 5 to 17 years;²⁰ this recommendation is addressed in a separate statement.²¹

Accuracy of Screening Tests

The USPSTF found limited evidence on available and appropriate screening instruments or clinical risk assessments to identify adults with oral health conditions in the primary care setting. The review identified 6 studies (n = 1281) of self-reported questionnaires on perceived dental health designed to distinguish between persons with and without periodontitis, but most questionnaires included whether there was a history of periodontitis, making them less relevant for screening in asymptomatic persons or those with previously unrecognized oral periodontitis.^1,19 The questionnaires demonstrated moderate discrimination (area under summary receiver operating characteristic curve, 0.79 [95% CI, 0.75-0.83]).^1,19 The evidence review did not identify any questionnaires designed to identify adults with dental caries.

The single primary care study²² (n = 86) evaluating the accuracy of clinical examination to identify dental caries found high specificity for dental caries and periodontitis (range, 0.80-0.93) but low sensitivity for periodontitis (0.56 [95% CI, 0.38-0.74] and 0.42 [95% CI, 0.24-0.56] for 2 examiners) and variable sensitivity for dental caries (0.33 [95% CI, 0.12-0.62] and 0.83 [95% CI, 0.52-0.96]).^1,19

The review found no evidence on the accuracy of risk assessment tools 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 persons²³ (n = 477) that compared no screening with a dental screening approach involving 2 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.^1,19,23

Harms of Screening

The same single study²² (n = 477) evaluating screening vs no screening in pregnant persons did not report examining harms of screening.^1,19

Effectiveness of Preventive Interventions

The USPSTF sought evidence on 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.^1,19

The following discussion focuses on preventive medications. Studies often had significant methodological limitations (eg, high attrition, unclear randomization, or uncertain applicability to the US) 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.^1,19

Topical Fluoride

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.^1,19 In the single randomized clinical trial²⁴ (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 statistically nonsignificant reduction in dental caries at 1 year (mean difference in new active dental caries or fillings, 0.7; P > .05), but at 2 and 3 years, group differences were statistically significant (mean difference, 1.8; P < .001 and mean difference, 1.6; P < .001, respectively).^1,19 In addition, fluoride varnish was associated with decreased risk of developing new dental caries (relative risk, 0.25 [95% CI, 0.10-0.63]), translating to a number needed to treat of 3.1 (95% CI, 2.1-7.7).^1,19 A nonrandomized cluster trial²⁵ (n = 232) of older adults in long-term care facilities found no group differences in dental caries burden (based on DMFT/DFT [Decayed, Missing, and Filled Teeth/Decayed, Filled Teeth] score) at 1 year (adjusted mean difference, −0.04 [95% CI, −0.10 to 0.03]).^1,19 The 3 additional trials of other topical fluoride 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.^1,19

Sealants, Silver Diamine Fluoride, 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.^1,19 Three trials (n = 590) examined the effectiveness of silver diamine fluoride solution to reduce dental caries or fillings in older adults.^1,19 Fluoride exposure (ie, oral health behaviors) was reported in 1 study and not reported in 2 studies.^1,19 In older adults, evidence suggests that silver diamine fluoride 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 Silver diamine fluoride may also reduce likelihood of developing new root dental caries (adjusted odds ratio, 0.4 [95% CI, 0.3-0.7] and relative risk, 0.19 [95% CI, 0.07-0.46] in 2 randomized clinical trials; n = 478).^1,19 No evidence was found evaluating the effects of xylitol to prevent dental caries or periodontitis.^1,19

Harms of Preventive Interventions

The review found very limited evidence on the harms of interventions. Of the 9 studies reviewed assessing preventive interventions, 1 trial evaluating fluoride varnish or silver diamine fluoride (vs placebo) stated “no major side effects or discomfort was reported.”^1,19,24 Eight other trials did not report examining for harms.^1,19

Response to Public Comment

A draft version of this recommendation statement was posted for public comment on the USPSTF website from May 23, 2023, to June 20, 2023. Some comments suggested that a recommendation supporting primary care screening and preventive interventions could expand dental care access and positively impact oral health disparities. The USPSTF is committed to advancing health equity and to the provision of equitable clinical preventive services to improve health. The USPSTF carefully considers evidence of benefits and harms, makes recommendations when supported by sufficient evidence, and makes recommendations on primary care–relevant services. However, based on the evidence, the USPSTF cannot recommend for or against oral health screening or preventive interventions for adults in the primary care setting. Primary care clinicians should use their clinical expertise to decide whether to perform these services. The USPSTF is calling for additional research to fill critical evidence gaps on this topic. Several comments agreed that the evidence is too limited to make a recommendation for or against primary care–feasible oral health screening or preventive interventions in adults.

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

The US Department of Health and Human Services’ Report of the Surgeon General (2000) and the National Institutes of Health’s update (2021) 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 US 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.²⁶ The American Academy of Family Physicians (2018) recommends that primary care clinicians educate patients about risks and benefits of fluoride use.²⁷ 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 life span.²⁸

The US Preventive Services Task Force members include the following individuals: Michael J. Barry, MD (Harvard Medical School, Boston, Massachusetts); Wanda K. Nicholson, MD, MPH, MBA (George Washington University, Washington, DC); Michael Silverstein, MD, MPH (Brown University, Providence, Rhode Island); David Chelmow, MD (Virginia Commonwealth University, Richmond); Tumaini Rucker Coker, MD, MBA (University of Washington, Seattle); Esa M. Davis, MD, MPH (University of Maryland School of Medicine, Baltimore); Katrina E. Donahue, MD, MPH (University of North Carolina at Chapel Hill); Carlos Roberto Jaén, MD, PhD, MS (University of Texas Health Science Center, San Antonio); Li Li, MD, PhD, MPH (University of Virginia, Charlottesville); Gbenga Ogedegbe, MD, MPH (New York University, New York, New York); Lori Pbert, PhD (University of Massachusetts Chan Medical School, Worcester); Goutham Rao, MD (Case Western Reserve University, Cleveland, Ohio); John M. Ruiz, PhD (University of Arizona, Tucson); James Stevermer, MD, MSPH (University of Missouri, Columbia); Joel Tsevat, MD, MPH (University of Texas Health Science Center, San Antonio); Sandra Millon Underwood, PhD, RN (University of Wisconsin, Milwaukee); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).

Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Role of the Funder/Sponsor: AHRQ staff assisted in the following: development and review of the research plan, commission of the systematic evidence review from an Evidence-based Practice Center, coordination of expert review and public comment of the draft evidence report and draft recommendation statement, and the writing and preparation of the final recommendation statement and its submission for publication. AHRQ staff had no role in the approval of the final recommendation statement or the decision to submit for publication.

Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.

Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.

AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.

This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.

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Abbreviation: US Preventive Services Task Force.