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Task Force on Community Preventive Services. The Guide to Community Preventive Services. Atlanta (GA): Centers for Disease Control and Prevention; 1999-.
This publication is provided for historical reference only and the information may be out of date.
Recommendations on Selected Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries
Task Force on Community Preventive Services.
Author Information and Affiliations
Published: 2002.
Medical Subject headings (MeSH): cariostatic agents; community dentistry; community health planning; community health services; decision making; dental caries; evidence-based medicine; facial injuries; intervention studies; mouth protectors; oral health; pharyngeal neoplasms; pit and fissure sealants; practice guidelines; preventive dentistry; preventive health services; public health dentistry; public health practice; review literature; tooth injuries
Introduction
Despite substantial improvements in oral health for most people in the United States during the 20th century, an estimated $60 billion is still spent annually on dental services. 1 About 500 million visits are made each year to dental offices, 2 and estimated inpatient hospital charges for diseases of the mouth and disorders of the teeth and jaw totaled $451 million in 1996. 2 Dental caries, oral cancers, and sports-related craniofacial injuries are potentially preventable conditions. The financial and human costs associated with these conditions, including mortality, indicate the need for interventions that promote oral health and prevent disease throughout the human life span.
This report provides recommendations on community interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. These conditions were chosen because they are important health problems that contribute substantially to annual dental care expenditures, serve as selected indicators of the need for preventive services, are potentially preventable by strategies already in widespread use, and address several of the Healthy People 2010 3 objectives (see Table 1 in Truman et al. 4 in this supplement).
Table
Table 1. Selected oral health objectives --Healthy People 2010 .
This report and other related publications (this volume is one in a series of AJPM supplements, reporting on findings of the Task Force on Community Preventive Services [the Task Force]) can provide guidance from the Task Force to personnel in state and local health departments, managed care organizations, purchasers of health care, people responsible for funding public health programs, and others who have interest in or responsibility for improving oral and related general health in all segments of the population.
The specific methods for and results of the reviews of evidence on which these recommendations are based are provided in the accompanying article. 4 General methods employed in evidence reviews for the Guide to Community Preventive Services (the Community Guide) have been published previously. 5
Intervention Recommendations
The Task Force evaluated the evidence of effectiveness of five interventions in the following areas: (1) strategies to prevent or control dental caries; (2) strategies to prevent or control oral and pharyngeal cancers; and (3) strategies to prevent or control sports-related craniofacial injuries.
Interventions to Prevent or Control Dental Caries
Comprehensive population-based interventions to prevent or control dental caries aim to (1) increase public and professional awareness of opportunities for organized action; (2) promote practices that improve the oral environment (e.g., reducing consumption of refined sugar and brushing with fluoride toothpaste); (3) ensure optimal exposure to fluoride from all sources (including community water fluoridation); and (4) ensure access to and efficient use of regular dental care, both preventive and restorative, including optimal use of sealants delivered in school-based or school-linked settings. 6 This report examines the evidence of the effectiveness of three interventions to prevent and control dental caries at the community level: community water fluoridation, school-based or school-linked pit and fissure sealant delivery programs, and statewide or community-wide sealant promotion programs.
Community water fluoridation: strongly recommended
Community water fluoridation (CWF) is the controlled addition of a fluoride compound to a public water supply to achieve an optimal fluoride concentration. 7 Since 1962, the U.S. Public Health Service has recommended that community drinking waters contain 0.7 to 1.2 ppm of fluoride. 7 In 1992, more than 144 million people in the United States (56% of the population and 62% of those receiving municipal water supplies) were being supplied with water containing enough fluoride to protect teeth from caries. In 2000, a total of 38 states and the District of Columbia provided access to fluoridated public water supplies to ≥50% of their populations. 7 A national objective aims to ensure that at least 75% of the population will be served by community water systems providing optimal levels of fluoride by the year 2010. 3
CWF is strongly recommended based on its effectiveness in reducing the occurrence of dental caries within communities. Other positive effects mentioned, but not systematically evaluated, include (1) reducing disparities in caries risk and experience across subgroups defined by socioeconomic status, race or ethnicity, and other predictors of caries risk 8 ; and (2) the "halo" or "diffusion" benefits to residents of nonfluoridated communities by means of exposure to processed food and beverages made from fluoridated water. 9
The safety of fluoride is well documented and has been reviewed comprehensively.6,8,10 Enamel fluorosis (visible discoloration of tooth enamel) is one of the potential adverse effects seen in children who ingest too much fluoride from any and all sources while tooth enamel is forming. Most cases of enamel fluorosis seen today are of the mildest form, which does not affect aesthetics or function. The most recent review of potential adverse effects of CWF showed no clear association between water fluoridation and incidence of mortality from bone cancers, thyroid cancer, or all cancers. 8
Program costs of CWF are affordable. Median cost per person per year ranges from $2.70 among 19 public water systems serving ≤5000 people to $0.40 among 35 systems serving populations ≥20,000. Estimated cost-effectiveness ratios (i.e., net cost per tooth surface spared from decay) indicate that CWF is cost saving (i.e., saves money from a societal perspective and also reduces caries). 4
School-based or school-linked pit and fissure sealant delivery programs: strongly recommended
School-based or school-linked pit and fissure sealant delivery programs directly provide pit and fissure sealants to children unlikely to receive them otherwise. School-based programs are conducted entirely in the school setting, and school-linked programs are conducted in both schools and clinic settings outside schools. Such programs define a target population within a school district; verify unmet need for sealants (by conducting surveys); get financial, material, and policy support; apply rules for selecting schools and students; screen and enroll students at school; and apply sealant at school or offsite in clinics. Many programs target what are referred to as high-risk children with high-risk teeth.3,6 High-risk children include vulnerable populations less likely to receive private dental care, such as children eligible for free or reduced-cost lunch programs. 6 High-risk teeth (i.e., those with deep pits and fissures) are the first and second permanent molars that erupt into the mouth around the ages of 6 and 12 years, respectively. School-based and school-linked sealant delivery programs are strongly recommended on the basis of strong evidence of effectiveness in reducing caries on occlusal surfaces of posterior teeth among children.
Other potential positive and negative effects of school-based or school-linked sealant delivery programs have been mentioned but remain unsupported by empirical evidence of effectiveness. For example, successful programs may lead to the positive effects of (1) increased support for coordinated school-based programs to address related dental and nondental needs of children from low-income families (e.g., immunization and better nutrition); and (2) increased willingness of third-party payers to pay for sealants applied in all settings. Potential negative effects are expressed in concerns that (1) sealants containing Bisphenol-A may have estrogenic effects in the recipient; and (2) effective delivery of sealants (from all sources) might encourage recipients to ignore other anticaries interventions (e.g., use of fluorides).
Economic evaluation studies reported sealant program costs per person served ranging from $18.50 to $59.83 (median=$39.10). The cost effectiveness ratios (adjusted cost per averted decayed surface) ranged from cost saving (<$0) to $487. A hypothetical school-based sealant program that sealed first permanent molars would be cost saving if unsealed molars were decaying at the average rate of >0.47 surfaces per year.
Statewide or community-wide sealant promotion programs: insufficient evidence
Statewide or community-wide sealant promotion programs encourage sealant use among private practitioners and through community-based programs. Program activities include continuing education courses for dental health professionals; educational campaigns for consumers, community leaders, and third-party payers; and efforts to promote school-based or school-linked sealant delivery programs. Statewide or community-wide sealant promotion programs aim to increase public and professional awareness of the health benefits of sealants, encourage third-party reimbursement for sealant application, increase appropriate use of sealants by practitioners, and increase access to sealants for disadvantaged populations who might not get them otherwise (e.g., through school-based programs). The one available study that evaluated a statewide sealant promotion campaign provided insufficient evidence to assess the program's effectiveness in changing public or professional behavior or in reducing dental caries statewide. The evidence was insufficient because of limitations in study design and execution, which did not allow valid attribution of reported changes in sealant use to the intervention.
Interventions to Prevent or Control Oral and Pharyngeal Cancers
Since 1992, organized efforts to develop and implement a national strategic plan for preventing and controlling oral and pharyngeal cancers have been gaining momentum in the United States. 11 In 1996, a coalition of national, state, and local health agencies began promoting coordinated strategies in five areas: (1) advocacy, collaboration, and coalition building; (2) public health policy; (3) public education; (4) professional education and practice; and (5) data collection, evaluation, and research. Despite the organized efforts described above, the effectiveness of population-based interventions to prevent and control oral and pharyngeal cancers, specifically to reduce mortality or improve quality of life, remains unknown.
Population-based interventions for early detection of pre-cancers and cancers: insufficient evidence
Population-based interventions for early detection of pre-cancers and cancers educate the public about risk factors, symptoms, signs, and the value of early detection; encourage high-risk or symptomatic individuals to examine themselves for suspicious lesions and to seek out a source of professional examination and follow-up; train health workers to detect suspicious lesions; examine people at the workplace, home, health fairs, field clinics, or the usual source of care; and refer eligible people with suspicious lesions (e.g., leukoplakia, erythroplakia, lichen planus, submucous fibrosis, and oral cancer) for follow-up and treatment.
The Task Force identified 19 studies with limited quality of execution. Those studies provide insufficient evidence of the effectiveness of early detection programs in improving stage distribution, morbidity, mortality, or quality of life at the population level.
Interventions to Prevent or Control Sports-Related Craniofacial Injuries
The consequences of sports-related injuries (e.g., bone fractures, tooth loss, concussions, brain damage) range from something as simple yet frustrating as a loss of game time to the much more serious events of paralysis and death. Helmets, facemasks, and mouthguards protect users from injuries to the head, face, and mouth. Protective equipment is mandatory in some professional sports: baseball requires use of helmets, football requires helmets and facemasks, ice hockey requires helmets, and boxing requires mouthguards. In amateur sports, helmets, facemasks, and mouthguards are mandatory in boxing, football, ice hockey, and men's lacrosse, and mouthguards are mandatory in women's field hockey. Healthy People 2010 3 established a developmental objective to increase the proportion of public and private schools that require use of appropriate head, face, eye, and mouth protection for students participating in school-sponsored physical activities.
Population-based interventions to encourage use of helmets, facemasks, and mouthguards in contact sports: insufficient evidence
Population-based interventions to encourage the use of helmets, facemasks, and mouthguards in contact sports aim to prevent injuries to the head, face, and mouth. Rules of play involving use of helmets, facemasks, goggles, and mouthguards vary by sport and position played. Intervention programs educate health professionals, parents, coaches, players, and officials of organized sports about the risks of injury and the potential benefits of protective equipment; offer incentives for regular use of protective equipment at both practice and formal competition; and encourage the enforcement of rules of play involving use of safety equipment. The Task Force identified four qualifying studies that evaluated the effectiveness of intervention programs in (1) increasing the frequency of correct use of helmets, facemasks, and mouthguards; and (2) reducing the incidence, prevalence, or recurrence and type and severity of sports-related injuries to the head, face, and mouth. Those studies provide insufficient evidence of the effectiveness of such programs in changing the behavior of players or in reducing the frequency of sports-related injuries to the head, face, and mouth. Although effectiveness could not be established, mainly because of inadequate number, design, or execution of studies, readers are reminded that the use of helmets, facemasks, and mouthguards is mandatory in many sports and encouraged by a Healthy People 2010 objective. 3
Interpreting and Using the Recommendations
Given that oral health conditions cause considerable morbidity and even mortality, and that activities to promote oral health are ongoing throughout the United States, the recommendations in this report should be relevant to most communities. Communities, school systems, healthcare systems, and oral health practitioners should consider starting program planning and implementation cycles by
- Assessing their goals in light of national goals and objectives 3 ;
- Assessing the current burden of oral health conditions in their populations;
- Reviewing the current status and history of intervention activities; and
- Identifying opportunities for improving intervention effectiveness and oral health status.
The Task Force has strongly recommended community water fluoridation and school-based or school-linked pit and fissure sealant delivery programs. Although the Task Force generally does not use economic information to modify recommendations, this information, provided in the accompanying article, 4 can help local policymakers in the decision-making process. If local goals and resources permit, the use of these interventions should be initiated or increased. In addition, these particular interventions should be considered in the context of other community-wide, provider-based, and individual strategies for preventing or controlling dental caries in communities.3,6,7
The Task Force's decision to make no recommendation for or against the use of three other reviewed interventions at the community level (statewide or community-wide sealant promotion programs; population-based interventions for early detection of pre-cancers and cancers; and population-based interventions to encourage use of helmets, facemasks, and mouthguards in contacts sports) indicates the need for high-quality research on their effectiveness. Until the results of such research become available, readers may judge the usefulness of these interventions based on other criteria. Although the effectiveness of community-wide sealant promotion programs remains unknown, the clinical safety and effectiveness of sealants have been established.15,16
Where organized efforts are being considered to reduce the burden of oral cancer, the findings presented here should be considered together with recommendations of other groups.6,11,13,17,18 For example, more widespread use of effective strategies to reduce tobacco use, an important cause of oral and pharyngeal cancer, 6,18,19,20 should be encouraged and periodic oral examinations of people engaging in risk behaviors (tobacco use or excessive alcohol consumption) or manifesting suspicious symptoms may be considered by clinicians. 6,13
Finally, in the absence of a community-wide recommendation on use of protective head and face equipment in contact sports, it should be noted that the frequency and severity of head, face, and oral injuries have decreased in some sports since the use of helmets, facemasks, and mouthguards became mandatory in selected organized contact sports (e.g., football and ice hockey).21,22
References
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- Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project, 2001. Available at: www
.ahrq.gov/data/hcup/hcupnet.htm. Accessed November 1, 2001. - 3.
- U.S. Department of Health and Human Services. 2000. Healthy People 2010. 2nd ed. With understanding and improving health and objectives for improving health.2 vols. Washington, DC: U.S. Government Printing Office. [PMC free article: PMC384376]
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- Truman BI, Gooch BF, Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med. 2002;23(suppl 1):21–54. [PubMed: 12091093]
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- Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Morb Mortal Wkly Rep. 2001. pp. 1–42. [PMC free article: PMC114895] [PubMed: 11521913]
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- McDonagh MS, Whiting PF, Wilson PM, et al. Systematic review of water fluoridation. BMJ. 2000;321:855–9. [PMC free article: PMC27492] [PubMed: 11021861]
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- Griffin SO, Gooch BF, Lockwood SA, Tomar SL. Quantifying the diffused benefit from water fluoridation in the United States. Community Dent Oral Epidemiol. 2001;29:120–9. [PubMed: 11300171]
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- Institute of Medicine, Food and Nutrition Board. Dietary reference intakes: calcium, phosphorus, magnesium, vitamin D, and fluoride, Washington, DC: National Academy Press 1997. [PMC free article: PMC176006] [PubMed: 23115811]
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- Ripa LW. Sealants revisited: an update of the effectiveness of pit-and-fissure sealants. Caries Res. 1993;27(suppl 1):77–82. [PubMed: 8500131]
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- Smith RA, Mettlin CJ, Davis KJ, Eyre H. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin. 2000;50:34–49. [PubMed: 10735014]
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- U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: report of the U.S. Preventive Services Task Force, 2nd ed, Baltimore, , MD: . Williams & Wilkins 1996. [PMC free article: PMC190016]
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.surgeongeneral.gov/tobacco. Accessed July 13, 2000 . - 20.
- Hopkins DP, Husten CG, Fielding JE, Rosenquist JN, Westphal LL. Evidence reviews and recommendations on interventions to reduce tobacco use and exposure to environmental tobacco smoke: a summary of selected guidelines. Am J Prev Med. 2001;20(suppl 2):67–87. [PubMed: 11173216]
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Medical Subject headings (MeSH): cariostatic agents; community dentistry; community health planning; community health services; decision making; dental caries; evidence-based medicine; facial injuries; intervention studies; mouth protectors; oral health; pharyngeal neoplasms; pit and fissure sealants; practice guidelines; preventive dentistry; preventive health services; public health dentistry; public health practice; review literature; tooth injuries
The names and affiliations of the Task Force members are listed at the beginning of this supplement, and at www
.thecommunityguide.org. Address reprint requests to: Community Guide Branch, Centers for Disease Control and Prevention, 4770 Buford Highway, MS-K73, Atlanta, GA 30341. .vog.cdc@ediugytinummoc :liam-E
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