TITLE: Pediatric Oral Health Risk Assessments in Primary Care Settings: Clinical Effectiveness and Guidelines

Transcription

1 TITLE: Pediatric Oral Health Risk Assessments in Primary Care Settings: Clinical Effectiveness and Guidelines DATE: 25 February 2016 RESEARCH QUESTIONS 1. What is the clinical effectiveness of oral health risk assessment by non-dental health professionals for improving oral health outcomes in pediatric patients younger than six years old? 2. What are the evidence-based guidelines for non-dental health professionals regarding the delivery of oral health risk assessments of children from birth to six years? KEY FINDINGS One systematic review, one randomized controlled trial, eight non-randomized studies, and five evidence-based guidelines were identified regarding oral health risk assessment by non-dental health professionals for improving oral health outcomes in pediatric patients younger than six years old. METHODS A limited literature search was conducted on key resources including PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit retrieval by publication type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2006 and February 9, Internet links were provided, where available. The summary of findings was prepared from the abstracts of the relevant information. Please note that data contained in abstracts may not always be an accurate reflection of the data contained within the full article. Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic review s. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts w ithin the time allow ed. Rapid responses should be considered along w ith other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for w hich little information can be found, but w hich may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that ef fect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material and may contain material in w hich a third party ow ns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a w eb site, redistributed by or stored on an electronic system w ithout the prior w ritten permission of CADTH or applicable copyright ow ner. Links: This report may contain links to other information available on the w ebsites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.

2 SELECTION CRITERIA One reviewer screened citations and selected studies based on the inclusion criteria presented in Table 1. Population Intervention Comparator Outcomes Study Designs Table 1: Selection Criteria Pediatric patients younger than 6 years Oral health risk assessments delivered by primary care physicians, pediatricians, nurses (non-dental health professionals) None; Risk assessments by dentists Q1: identifying children who are in need of dental prevention (such as fluoride varnish), increase in the use of fluoride varnish, decrease in dental caries Q2: best practice regarding the identification of children at risk, guidelines regarding what the cutoff is for at risk, guidelines regarding the delivery of oral health risk assessments by non-dental health professionals Health technology assessments, systematic reviews, meta-analyses, randomized controlled trials, non-randomized studies, evidence-based guidelines RESULTS Rapid Response reports are organized so that the higher quality evidence is presented first. Therefore, health technology assessment reports, systematic reviews, and meta-analyses are presented first. These are followed by randomized controlled trials, non-randomized studies, and evidence-based guidelines. One systematic review, one randomized controlled trial, eight non-randomized studies, and five evidence-based guidelines were identified regarding oral health risk assessment by non-dental health professionals for improving oral health outcomes in pediatric patients younger than six years old. No relevant health technology assessments were identified. Additional references of potential interest are provided in the appendix. OVERALL SUMMARY OF FINDINGS One systematic review, 1 one randomized controlled trial, 2 and eight relevant non-randomized studies 3-10 were identified. The results of these studies are summarized in Table 2. Generally, the results of the studies suggest that dental assessment by non-dental providers was able to detect caries in children but suggested that non-dental practitioners may require further education and training to more accurately identified children at higher risk of early childhood caries. Five evidence-based guidelines were identified. The guidelines differ slightly in terms of recommending when initial risk assessment should be undertaken. The guidelines recommend dental risk assessment be undertaken by six months of age 12 or by one year of age. 11 One guideline determined there is insufficient evidence to recommend routine screening for dental caries by primary physicians for children five years of age and younger. 13 The recommendations suggest primary care physicians should prescribe oral fluoride supplementation after six months Pediatric Oral Health Risk Assessments in Primary Care Settings 2

3 of age for children whose water supply does not contain fluoride and should apply fluoride varnish to all primary teeth of all children starting at the age of initial tooth eruption. 13 Table 2: Summary of Included Studies First Author, Year Population/Provider Results Conclusions Systematic Reviews Chou, Children less than 5 years of age Randomized Controlled Trials Slade, Cluster randomized trial Primary care clinicians Australian aboriginal children aged 18 to 47 months Primary health care workers Non-Randomized Studies Jackson, Children up to 18 months of age Kranz, Primary care physician Kindergarten students Non-dental providers in medical settings No studies were identified assessing the use of risk assessment tools to identify increased risk of dental caries. Dental health program (fluoride varnish, education, dental health promotion) vs no intervention After 2 years, the net dental caries increment per child was significantly lower in the intervention group. Identification of children at high risk for early childhood caries was improved after the implementation of a quality improvement project. Children with 4 or more medical visits with POHS had significantly fewer than children with no POHS. concluded that further research was required to determine the accuracy of oral examination and risk assessment by primary care providers. concluded that fluoride varnish applied in the community was effective at preventing dental caries. No authors conclusions were provided in the abstract. determined that POHS by non-dental providers were associated with a reduction in caries but not an increase in subsequent use services in dental settings. Pediatric Oral Health Risk Assessments in Primary Care Settings 3

4 Table 2: Summary of Included Studies First Author, Year Population/Provider Results Conclusions Achembong, Children 0 to 4 years of age (from primarily low income families) Dumas, Preventive dentistry program in primary care medical offices 15 months to 5 years of age Pediatric health providers Long, Children less than 36 months of age Pediatricians Neumann, Children less than 3 years of age (nonfluoridated, rural setting) Community-based dental health intervention After the implementation of a preventive dental care program, mean dmft per kindergarten student initially increased from 1.53 to 1.84, then decreased to Providers were able to identify visible plaque on maxillary incisors on 39% of children (55% sensitivity, 80% specificity). Agreement with a dental hygienist measured a kappa score of Using a POORT, pediatricians assessed risk factors for early childhood caries. Of the children assessed, 6.8% were identified as needing an evaluation by a dentist. Children in the intervention group (fluoridated toothpaste, educational interventions) experienced fewer dental caries than those in the control group at the first two exams. The differences were no longer apparent at exam 3. concluded that the program was successful at decreasing dental caries in the targeted, vulnerable study population. Visible plaque exams performed by clinicians at well child visits were not always accurate. concluded that providers may require further training in conducting oral health exams. observed low referral raters by physicians and determines that interventions were required to increase the rate of referral of children to dentists. concluded that the intervention was successful for reducing caries earlier in life but became less effective as the participants had less contact with the community health workers. Pediatric Oral Health Risk Assessments in Primary Care Settings 4

5 Table 2: Summary of Included Studies First Author, Year Population/Provider Results Conclusions Minah, Children aged 6 to 27 months (low income) Pediatric primary care clinic Grant, Children less than 3 years of age Non-dental providers in medical settings Children in the intervention group received preventive services (risk assessment, fluoride varnish, counselling, dental referral) and experienced fewer mean carious dental surfaces. 4.4% (29/655) patients were reported to have one or more caries. 14.1% (94/655) patients were referred to a dentist. concluded that administering preventive measures to children of low socioeconomic status was effective to reduce dental caries. concluded that the intervention was effective and also contributed to the financial viability of the clinic in which the intervention took place. dmft = decayed, missing, and filled primary teeth; POHS = preventive oral health services; POORT = priority oral health risk assessment and referral tool Pediatric Oral Health Risk Assessments in Primary Care Settings 5

6 REFERENCES SUMMARIZED Health Technology Assessments No literature identified. Systematic Reviews and Meta-analyses 1. Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M. Prevention of Dental Caries in Children Younger Than 5 Years Old: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 May. (U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews). Randomized Controlled Trials 2. Slade GD, Bailie RS, Roberts-Thomson K, Leach AJ, Raye I, Endean C, et al. Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial. Community Dent Oral Epidemiol. [Internet] Feb [cited 2016 Feb 23];39(1): Available from: PubMed: PM Non-Randomized Studies 3. Jackson EB. Outcomes of a quality improvement project examining early childhood caries and improving identification of at risk patients in a pediatric medical home setting. J Pediatr Nurs Jul;30(4): PubMed: PM Kranz AM, Preisser JS, Rozier RG. effects of physician-based preventive oral health services on dental caries. Pediatrics Jul;136(1): PubMed: PM Achembong LN, Kranz AM, Rozier RG. Office-based preventive dental program and statewide trends in dental caries. Pediatrics Apr;133(4):e827-e834. PubMed: PM Dumas SA, Weaver KE, Park SY, Polk DE, Weyant RJ, Bogen DL. Accuracy of visible plaque identification by pediatric clinicians during well-child care. Clin Pediatr (Phila) [Internet] Jul [cited 2016 Feb 23];52(7): Available from: PubMed: PM Long CM, Quinonez RB, Beil HA, Close K, Myers LP, Vann WF, Jr., et al. Pediatricians' assessments of caries risk and need for a dental evaluation in preschool aged children. BMC Pediatr [Internet] [cited 2016 Feb 23];12:49. Available from: PubMed: PM Pediatric Oral Health Risk Assessments in Primary Care Settings 6

7 8. Neumann AS, Lee KJ, Gussy MG, Waters EB, Carlin JB, Riggs E, et al. Impact of an oral health intervention on pre-school children < 3 years of age in a rural setting in Australia. J Paediatr Child Health Jun;47(6): PubMed: PM Minah G, Lin C, Coors S, Rambob I, Tinanoff N, Grossman LK. Evaluation of an early childhood caries prevention program at an urban pediatric clinic. Pediatr Dent Nov;30(6): PubMed: PM Grant JS, Roberts MW, Brown WD, Quinonez RB. Integrating dental screening and fluoride varnish application into a pediatric residency outpatient program: clinical and financial implications. J Clin Pediatr Dent. 2007;31(3): PubMed: PM Guidelines and Recommendations 11. Dental interventions to prevent caries in children [Internet]. Edinburgh: Scottish Intercollegiate Guidelines Network; 2014 Mar. [cited 2016 Feb 24]. (SIGN publication no. 138). Available from: See: Recommendations, page Guideline on infant oral health care. Reference Manual (American Academy of Pediatric Dentistry) [Internet] [cited 2016 Feb 24];37(6): Available from: See: Recommendations for the infant s oral health, page Moyer VA, US Preventive Services Task Force. Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement. Pediatrics Jun;133(6): PubMed: PM Guideline summary: Oral health: local authorities and partners [Internet]. London: National Institute for Health and Care Excellence; [cited 2016 Feb 24]. (Public health guideline; no. 55). Available from: Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, et al. Preventitive services for children and adolescents [Internet]. 19th ed. Bloomington (MN): Institute for Clinical Systems Improvement; 2013 Sep. [cited 2016 Feb 24]. (Health care guideline). Available from: See: 13. Oral Health Counseling and Treatments (Level II), page 23 PREPARED BY: Canadian Agency for Drugs and Technologies in Health Tel: Pediatric Oral Health Risk Assessments in Primary Care Settings 7

8 APPENDIX FURTHER INFORMATION: Clinical Practice Guidelines 16. Considerations for oral health integration in primary care practice for children [Internet]. [Rockville (MD)]: U.S. Department of Health and Human Service, Health Resources and Services Administration; 2012 Dec. [cited 2016 Feb 24]. Available from: Integration of oral health and primary care practice [Internet]. [Rockville (MD)]: U.S. Department of Health and Human Service, Health Resources and Services Administration; 2014 Feb. [cited 2016 Feb 24]. Available from: Position Statements 18. Section On Oral Health. Maintaining and improving the oral health of young children. Pediatrics [Internet] Dec [cited 2016 Feb 23];134(6): Available from: PubMed: PM Rowan-Legg A, Canadian Paediatric Society, Community Paediatrics Committee. Oral health care for children - a call for action. Paediatr Child Health [Internet] Jan [cited 2016 Feb 24];18(1): Available from: PubMed: PM Irvine J, Holve S, Krol D, Schroth R. Early childhood caries in Indigenous communities: a joint statement with the American Academy of Pediatrics. Paediatr Child Health [Internet] Jun [cited 2016 Feb 23];16(6): Available from: PubMed: PM Assessment Tools 21. Custodio-Lumsden CL, Wolf RL, Contento IR, Basch CE, Zybert PA, Koch PA, et al. Validation of an early childhood caries risk assessment tool in a low-income Hispanic population. J Public Health Dent Oct 6. PubMed: PM D0145 Oral Evaluation for patients under 3 years of age [Internet]. [Augusta (ME)]: MaineCare Services; 2013 Dec 6. [cited 2016 Feb 23]. Available from: Assessmnet.pdf 23. Oral health risk assessment tool [Internet]. [Elk Grove Village (Il)]: American Academy of Pediatrics; [cited 2016 Feb 23]. Available from: 20Assessment%20Tool.pdf Pediatric Oral Health Risk Assessments in Primary Care Settings 8

9 Review Articles 24. Douglass JM, Clark MB. Integrating oral health into overall health care to prevent early childhood caries: need, evidence, and solutions. Pediatr Dent May;37(3): PubMed: PM Okunseri C, Gonzalez C, Hodgson B. Children's oral health assessment, prevention, and treatment. Pediatr Clin North Am Oct;62(5): PubMed: PM Hummel J, Phillips KE, Holt B, Hayes C. Oral health: an essential component of primary care [Internet]. Seattle (WA): Qualis Health; 2015 Jun. [cited 2016 Feb 23]. Available from: Primary-Care.pdf 27. Section On Oral Health. Maintaining and improving the oral health of young children. Pediatrics Dec;134(6): PubMed: PM Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. J Am Acad Nurse Pract Jan;21(1):1-10. PubMed: PM Section on Pediatric Dentistry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics [Internet] Dec [cited 2016 Feb 23];122(6): Available from: PubMed: PM Monroy PG. The age-1 dental visit and the dental home; a model for early childhood caries prevention. J Mich Dent Assoc Jan;89(1):32, 34-2, 36. PubMed: PM Ramos-Gomez FJ, Crall J, Gansky SA, Slayton RL, Featherstone JD. Caries risk assessment appropriate for the age 1 visit (infants and toddlers). J Calif Dent Assoc Oct;35(10): PubMed: PM Additional References 32. Schechtman T. Let's talk: pediatricians and oral health [Internet]. [Tallahassee (FL)]: Florida Chapter, American Academy of Pediatrics; 2015 Aug 21. [cited 2016 Feb 23]. Available from: Ramos-Gomez FJ. A model for community-based pediatric oral heath: implementation of an infant oral care program. Int J Dent[Internet] [cited 2016 Feb 23];2014: Available from: PubMed: PM Pediatric Oral Health Risk Assessments in Primary Care Settings 9

10 34. Ramos-Gomez FJ, Crystal YO, Domejean S, Featherstone JD. Minimal intervention dentistry: part 3. Paediatric dental care--prevention and management protocols using caries risk assessment for infants and young children. Br Dent J Nov;213(10): PubMed: PM Hallas D, Fernandez J, Lim L, Carobene M. Nursing strategies to reduce the incidence of early childhood caries in culturally diverse populations. J Pediatr Nurs Jun;26(3): PubMed: PM Turner S, Brewster L, Kidd J, Gnich W, Ball GE, Milburn K, et al. Childsmile: the national child oral health improvement programme in Scotland. Part 2: Monitoring and delivery. Br Dent J Jul 24;209(2): PubMed: PM Viswanathan K. Infant oral exam and first dental home. Tex Dent J Nov;127(11): PubMed: PM Pediatric Oral Health Risk Assessments in Primary Care Settings 10