Screening and Preventive Interventions for Oral Health in Adults: US Preventive Services Task Force Recommendation Statement | JAMA

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, and Native Hawaiian/Pacific Islander adults; pregnant persons; 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

See Table 1 for more information on the USPSTF recommendation rationale and assessment and the eFigure in the Supplement for information on the recommendation grade. See the Figure for a summary of the recommendation for clinicians. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.⁶

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.

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.

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

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.

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).

The USPSTF has issued recommendations on screening and interventions to prevent dental caries in children younger than 5 years15; screening for oral cancer¹⁶; interventions for tobacco smoking cessation in adults, including pregnant persons¹⁷; and screening and preventive interventions for oral health in children and adolescents aged 5 to 17 years.¹⁸

The USPSTF commissioned a systematic evidence review1^,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 years²⁰; this recommendation is addressed in a separate statement.²¹

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

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

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

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

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

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

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

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

Corresponding Author: Michael J. Barry, MD, Informed Medical Decisions Program, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (chair@uspstf.net).

The US Preventive Services Task Force (USPSTF) members: Michael J. Barry, MD; Wanda K. Nicholson, MD, MPH, MBA; Michael Silverstein, MD, MPH; David Chelmow, MD; Tumaini Rucker Coker, MD, MBA; Esa M. Davis, MD, MPH; Katrina E. Donahue, MD, MPH; Carlos Roberto Jaén, MD, PhD, MS; Li Li, MD, PhD, MPH; Gbenga Ogedegbe, MD, MPH; Lori Pbert, PhD; Goutham Rao, MD; John M. Ruiz, PhD; James Stevermer, MD, MSPH; Joel Tsevat, MD, MPH; Sandra Millon Underwood, PhD, RN; John B. Wong, MD.

Affiliations of The US Preventive Services Task Force (USPSTF) members: Harvard Medical School, Boston, Massachusetts (Barry); George Washington University, Washington, DC (Nicholson); Brown University, Providence, Rhode Island (Silverstein); Virginia Commonwealth University, Richmond (Chelmow); University of Washington, Seattle (Coker); University of Maryland School of Medicine, Baltimore (Davis); University of North Carolina at Chapel Hill (Donahue); The University of Texas Health Science Center, San Antonio (Jaén, Tsevat); University of Virginia, Charlottesville (Li); New York University, New York, New York (Ogedegbe); University of Massachusetts Chan Medical School, Worcester (Pbert); Case Western Reserve University, Cleveland, Ohio (Rao); University of Arizona, Tucson (Ruiz); University of Missouri, Columbia (Stevermer); University of Wisconsin, Milwaukee (Underwood); Tufts University School of Medicine, Boston, Massachusetts (Wong).

Author Contributions: Dr Barry had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The USPSTF members contributed equally to the recommendation statement.

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.

Additional Contributions: We thank Sheena Harris, MD, MPH (AHRQ), who contributed to the writing of the manuscript, and Lisa Nicolella, MA (AHRQ), who assisted with coordination and editing.

Additional Information: Published by JAMA®—Journal of the American Medical Association under arrangement with the Agency for Healthcare Research and Quality (AHRQ). ©2023 AMA and United States Government, as represented by the Secretary of the Department of Health and Human Services (HHS), by assignment from the members of the United States Preventive Services Task Force (USPSTF). All rights reserved.