Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Adults: A Systematic Review for the US Preventive Services Task Force

Importance

Dental caries and periodontal disease are common adult oral health conditions and potentially amenable to primary care screening and prevention.

Objective

To systematically review the evidence on primary care screening and prevention of dental caries and periodontal disease in adults to inform the US Preventive Services Task Force.

Data Sources

MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to October 3, 2022); surveillance through July 21, 2023.

Study Selection

Diagnostic accuracy studies of primary care screening instruments and oral examination; randomized and nonrandomized trials of screening and preventive interventions; cohort studies on primary care oral health screening and preventive intervention harms.

Data Extraction and Synthesis

One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Diagnostic accuracy data were pooled using a bivariate mixed-effects binary regression model.

Main Outcomes and Measures

Dental caries, periodontal disease, morbidity, quality of life, harms; and diagnostic test accuracy.

Results

Five randomized clinical trials, 5 nonrandomized trials, and 6 observational studies (total 3300 participants) were included. One poor-quality trial (n = 477) found no difference between oral health screening during pregnancy vs no screening in caries, periodontal disease, or birth outcomes. One study (n = 86) found oral health examination by 2 primary care clinicians associated with low sensitivity (0.42 and 0.56) and high specificity (0.84 and 0.87) for periodontal disease and with variable sensitivity (0.33 and 0.83) and high specificity (0.80 and 0.93) for dental caries. Four studies (n = 965) found screening questionnaires associated with a pooled sensitivity of 0.72 (95% CI, 0.57-0.83) and specificity of 0.74 (95% CI, 0.66-0.82) for periodontal disease. For preventive interventions no study evaluated primary care counseling or dental referral, and evidence from 2 poor-quality trials (n = 178) of sealants, and 1 fair-quality and 4 poor-quality trials (n = 971) of topical fluorides, was insufficient. Three fair-quality trials (n = 590) of persons with mean age 72 to 80 years found silver diamine fluoride solution associated with fewer new root caries lesions or fillings vs placebo (mean reduction, -0.33 to -1.3) and decreased likelihood of new root caries lesion (2 trials; adjusted odds ratio, 0.4 [95% CI, 0.3-0.7]). No trial evaluated primary care-administered preventive interventions.

Conclusions and Relevance

Screening questionnaires were associated with moderate diagnostic accuracy for periodontal disease. Research is needed to determine benefits and harms of oral health primary care screening and preventive interventions.

A systematic review on the effect of silver diamine fluoride for management of dental caries in permanent teeth

OBJECTIVES

The objective of this review is to assess the available literature systematically related to the effect of silver diamine fluoride (SDF) for the management of occlusal and root carious lesions in permanent teeth regardless of age. MATERIALS AND METHODS: This systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Review and Meta-Analyses statement. A literature search was performed using PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, DOAJ, and Open Gray with no language restrictions up to December 2022. Three reviewers critically assessed the studies for eligibility. Any disputes between the reviewers were handled by a fourth independent reviewer. The quality assessment and data extraction of the studies were performed.

RESULTS

A total of 2176 studies were screened. The titles and abstracts of the studies were then reviewed (n = 346), and 52 studies met the search criteria. Following the full-text review, 11 studies investigated the effect of SDF against other treatments such as chlorhexidine, sodium fluoride, ammonium bifluoride, tricalcium silicate paste, casein phosphopeptide amorphous calcium phosphate, glass ionomer cement (GIC) combined with fluoride varnish, resin-modified GIC, and atraumatic restorative treatment were assessed.

CONCLUSIONS

Within the limitations of this review, the use of SDF is promising with high preventative fractions in permanent teeth of children and older populations when compared to other topical applications such as dental varnish containing sodium fluoride.

Effectiveness of 38% Silver Diamine Fluoride Application along with Atraumatic Restorative Treatment for Arresting Caries in Permanent Teeth When Compared to Atraumatic Restorative Treatment in Adults-Study Protocol for a Randomized Controlled Trial

INTRODUCTION

Dental caries in the adult population that require preventive and therapeutic treatment are generally neglected in rural communities. The determination of the effectiveness of the application of 38% silver diamine fluoride (SDF) in arresting caries lesions when combined with atraumatic restorative treatment (ART) is very important, as it serves as a preventive and restorative procedure to regain the function of the permanent dentition. The assessment of optimal SDF application with ART, in comparison with ART alone, in managing cavitated carious lesions in a pragmatic setting, is the need of the hour to recommend optimal dental care, especially in rural settings which have minimal access to comprehensive dental care.

METHODS AND ANALYSIS

The clinical trial will enrol 220 adults (18-65 years) with cavitated carious lesions attending the Amrita School of Dentistry in the Ernakulam district, India. This study is a randomized, controlled trial with a 1:1 allocation ratio in two parallel groups. Study arm 1 will receive 38% SDF application and ART, and study arm 2 will receive ART only. A digital radiograph will be taken immediately after restoration (baseline) as well as at the end of the 6th month for evaluation of caries arrest. The assessment of the survival of the restoration will be done on the 7th day, 30th day, and at the end of the 6th month. The final analysis would include both the tooth and person levels.

ETHICS AND DISSEMINATION

This trial adheres to the principles of the Declaration of Helsinki and the guidelines of the Indian Council of Medical Research (ICMR). This study protocol has been approved by the Institutional Review Board. This trial has been registered prospectively with the Clinical Trial Registry of India (Registration No: CTRI/2021/12/038816).

The burden of root caries: Updated perspectives and advances on management strategies

BACKGROUND

Root caries has gained much attention in the last few years. As the world's population is ageing and people currently tend to retain more teeth compared with older generations, there is an increased prevalence of periodontal disease and gingival recession, which may accelerate the onset of root caries.

OBJECTIVE

This review aims to summarise recent findings related to the diagnosis, prevention and treatment of root caries.

MATERIALS AND METHODS

MEDLINE (OVID) and Scopus (Elsevier) searches were performed to identify and discuss articles that address the pathogenicity and clinical management of root caries.

RESULTS

Root caries is a multifactorial disease. Cariogenic species involved in root caries are less dependent on carbohydrates since collagen degradation inside the dentinal tubules can provide nutrients and microcavities for the invading microorganisms. Furthermore, the root surface has fewer minerals in comparison with enamel, which may accelerate the onset of demineralisation. Root caries could be prevented by patient education, modification of risk factors, and the use of in-office and home remineralisation tools. The use of non-invasive approaches to control root caries is recommended, as the survival rate of root caries restorations is poor. When plaque control is impossible and a deep/large cavity is present, glass ionomer or resin-based restorations can be placed.

CONCLUSION

The assessment of root carious lesions is critical to determine the lesion activity and the required intervention. Dental practitioners should also be aware of different prevention and treatment approaches to design optimum oral health care for root caries-affected patients.

Topical Fluoride to Prevent Root Caries: Systematic Review with Network Meta-analysis

The aim of this systematic review and network meta-analysis was to summarize the direct and indirect clinical evidence on the effectiveness of professionally applied and self-applied topical fluorides in preventing dental root caries. Controlled clinical trials with any follow-up duration were included. MEDLINE, PubMed, Embase, Scopus, and Cochrane Library were searched. Two reviewers independently carried out the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Fixed effects model and frequentist approach were used in the network meta-analyses. Nine clinical trials involving 4,030 participants were included. Five professionally applied and 7 self-applied topical fluoride agents or combinations were included in the meta-analyses. Compared to control group, 38% silver diamine fluoride solution, 5% sodium fluoride varnish, and 1.2% acidulated phosphate fluoride reduced root caries increment after 2 y (ranging from 0.59 to 0.85 mean decayed or filled root [DF-root]). Fluoride mouth rinse and fluoride toothpaste, used alone or in combination, reduced root caries increment after 1 y (ranging from 0.29 to 1.90 mean DF-root). Among the professionally applied topical fluorides reviewed, an annually applied 38% silver diamine fluoride (SDF) solution combined with oral health education is most likely to be the most effective in preventing dental root caries. Among the reviewed self-applied topical fluoride methods, daily use of a 0.2% sodium fluoride (NaF) mouth rinse is most likely to be the most effective, followed by 1100 ppm to 1500 ppm fluoride toothpaste plus 0.05% NaF mouth rinse, and 1100 ppm to 1500 ppm fluoride toothpaste.

Remineralisation - the buzzword for early MI caries management

Minimal intervention (MI) dentistry aims to preserve dental tissues first and restore only when indicated, thus remineralisation of initial (non-cavitated) caries lesions, an integral part of caries management, is an essential treatment strategy in MI. With this understanding, dental practitioners are increasingly embracing the principle of non-operative treatment of initial caries lesions. The purpose of this review was to summarise the most recent literature published in non-operative management of dental caries. Three electronic databases (MEDLINE, EMBASE, Cochrane CENTRAL) were searched, and clinical studies, systematic reviews and meta-analysis were included. This report outlines the strategies and numerous therapeutic materials available to aid in arrestment/remineralisation of initial caries lesions on root and coronal surfaces. However, the level of evidence of effect is variable, as well as the availability in different parts of the world. Options available to practitioners will vary when placing emphasis on the level of evidence supporting them. Strong clinical evidence support the effectiveness of pits/fissure sealants for therapeutic management of active initial caries on occlusal surfaces, and fluoride varnishes for remineralisation of caries lesions on root and coronal smooth surfaces, including proximal surfaces. Other materials formulated to enhance the effectiveness of any chosen remineralisation strategy were discussed. However, it is absolutely necessary that all caries remineralisation treatment be complemented with general behavioural modification in oral health through motivational interviewing directed towards change in oral hygiene to control plaque, dietary attitude modification to reduce the frequency of intake of fermentable sugars, and establishment of risk-based recall visits.