Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

JAMA. 2021 Dec 7;326(21):2179-2192. doi: 10.1001/jama.2021.15658.


Importance: A 2014 review for the US Preventive Services Task Force (USPSTF) found that oral fluoride supplementation and topical fluoride use were associated with reduced caries incidence in children younger than 5 years.

Objective: To update the 2014 review on dental caries screening and preventive interventions to inform the USPSTF.

Data sources: Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to September 2020); surveillance through July 23, 2021.

Study selection: Randomized clinical trials (RCTs) on screening, preventive interventions, referral to dental care; cohort studies on screening and referral; studies on diagnostic accuracy of primary care oral examination or risk assessment; and a systematic review on risk of fluorosis included in prior USPSTF reviews.

Data extraction and synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality.

Results: Thirty-two studies (19 trials, 9 observational studies, and 4 nonrandomized clinical intervention studies [total 106 694 participants] and 1 systematic review [19 studies]) were included. No study evaluated effects of primary care screening on clinical outcomes. One study (n = 258) found primary care pediatrician examination associated with a sensitivity of 0.76 (95% CI, 0.55 to 0.91) and specificity of 0.95 (95% CI, 0.92 to 0.98) for identifying a child with cavities, and 1 study found a risk assessment tool associated with sensitivity of 0.53 and specificity of 0.77 (n = 697, CIs not reported) for a child with future caries. No new trials of dietary fluoride supplementation were identified. For prevention, topical fluoride compared with placebo or no topical fluoride was associated with decreased caries burden (13 trials, n = 5733; mean caries increment [difference in decayed, missing, and filled teeth or surfaces], -0.94 [95% CI, -1.74 to -0.34]) and likelihood of incident caries (12 trials, n = 8177; RR, 0.80 [95% CI, 0.66 to 0.95]; absolute risk difference, -7%) in higher-risk populations or settings, with no increased fluorosis risk. Evidence on other preventive interventions was limited (education, xylitol) or unavailable (silver diamine fluoride), and no study directly evaluated primary care dentistry referral vs no referral.

Conclusions and relevance: There was no direct evidence on benefits and harms of primary care oral health screening or referral to dentist. Dietary fluoride supplementation and fluoride varnish were associated with improved caries outcomes in higher-risk children and settings.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Systematic Review

MeSH terms

  • Advisory Committees*
  • Cariostatic Agents / administration & dosage*
  • Child, Preschool
  • Cohort Studies
  • Dental Caries / diagnosis
  • Dental Caries / prevention & control*
  • Diagnosis, Oral
  • Fluorides / administration & dosage
  • Fluorides, Topical / administration & dosage*
  • Humans
  • Non-Randomized Controlled Trials as Topic
  • Observational Studies as Topic
  • Preventive Health Services
  • Randomized Controlled Trials as Topic
  • Referral and Consultation
  • Sensitivity and Specificity
  • Xylitol / administration & dosage


  • Cariostatic Agents
  • Fluorides, Topical
  • Fluorides
  • Xylitol