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Dental Medicine and Oral Health Sciences

The effect of an established dental home on caries control in children

Clinical Question: What is the effect of a dental home compared to its absence on caries experience and other oral health-related outcomes in 0-5 year-old children over a 5-year period?

Clinical Bottom Line: Overall, there is limited evidence of the effect of establishing a dental home on caries control in children. More research in the field is needed. This evidence suggests that early preventive dental visits (EPDVs) may be associated with reduced restorative dental care visits and related expenditures during the first years of life. The benefits of EPDVs for caries control are more evident among children at high risk or with existing caries disease. The evidence quality is appraised as low because of the small number ofprimary and secondary studies with rigorous methodology, variation in starting point of the preventive visits, the types of interventions and of outcomes, as well as the risk of selection and assessment bias. Moreover, the concept of ‘dental home’ is broad and does not have a clear definition. The effect of an early preventative approach under this concept depends on the type of intervention provided (one RCT, low risk of bias).

Evidence search:

"Dental Caries"[Mesh] AND (dental home*[tiab] OR preventive dental care*[tiab] OR preventive oral health care*[tiab] OR preventive dental visit*[tiab]). Limits applied: Child.

Search date: October 24, 2019; PubMed yield: 159 evidence sources; Additional search: ADA EBD website, TRIP database, AAPD website

Author, year Source of evidence Population Characteristics Methods

1. Bhaskar et al. 2014.
PMID: 24672258

Systematic Review (four retrospective cohort studies) Population: 0-6 year-old children
  • first year dental visit and early preventive visits
  • Public Medicaid insurance: US social health care program for low income individuals and families

Sample size: n = 7 291 (ranging from 9,204-36,805)

Setting: dental offices in North Carolina and Alabama

Search: PubMed and Embase databases, MeSH terms and keywords; not yet indexed articles

Interventions: early preventive dental visits (EPDVs): the concepts of theestablishment of a dental home, oral examinations, fluoride application, dental prophylaxis, anticipatory guidance.

Outcomes: caries (DMFT index), count of preventive/non-preventive dental visits, later expenditures for dental care

Key Results

From a total of 530 literature sources, four US-based retrospective cohort studies (published in 2012-2013, one in 2004) were selected. The timing of EPDV initiation varied from less than 12 months of age to 18–24 months, with a 6-month preventive checkup window. Time to follow up ranged from 24 to 60 months. One study found no benefit of EPDVs on caries development. The other three showed mixed support for EPDVs with regards to more future PDVs, reduced restorative dental care visits and lower future restorative dental expenditure.

Evidence Quality

Strengths

MeSH terms and keywords, additional search for not yet indexed articles; inclusion/exclusion criteria; two reviewers worked independently; summary table; multivariate regression analysis performed in all selected studies.

Limitations

Only two databases, no grey literature, no formal PRISMA diagram, no numerical data on studies results, no formal quality assessment of the primary studies. Primary studies: problem-driven dental care-seeking pattern (selection bias), Medicaid claims data (assessment bias), variations in the PICOT designs. There is no single outcome of interest common to all four studies, only one study focused on caries clinical outcome.

Author, year Source of evidence Population Characteristics Methods

2. Tickle et
al. 2016.
PMID:
27685609

Randomized Controlled Trial Population: 2–3 year old children
  • caries-free at baseline
  • children were categorized into quintiles based on the Northern Ireland Multiple Deprivation Measure
Sample size: n=1248
Setting: 22 general dental practices in Northern Ireland

Randomization: by clinical trials unit (CTU), using randomized permuted blocks

Allocation concealment: by the CTU on a dedicated trial telephone line Intervention: fluoride varnish (22,600 ppm F), a toothbrush and a 50-ml tube of toothpaste (1450 ppm F) + standardized dental health education and restriction of sugar consumption provided at 6-month intervals

Control: prevention advice alone, at 6-month intervals

Follow up: 3-year interval

Primary outcome: caries-free to caries-active, % (D3 level)

Secondary outcome: mean DMFS score (D3 level)

Analysis: Logistic model adjusted for age and socioeconomic status (SES)

Key Results

OR = 0.81 (95% CI 0.64, 1.04): children in the intervention group had 0.81 time odds of being caries active compared to the control group; MD = –2.29 (95%CI –3.96, –0.63): children in the intervention group had on average 2.29 less cavitated caries surfaces compared to the control group; Lost to follow up: 12% of children in the test group and the control group; There was no difference in the number of episodes of pain and tooth extractions between the study groups; Cost: the estimated mean cost per child kept decay free over the 3-year period was £2093.

Evidence Quality

Comments

There was no effect of the intervention on the prevention of conversion from a caries-free to a caries-active state. The results are not statistically significant, not clinically meaningful and precise, showing no effect (RD = -2% (95% CI -3.6 to 0.4), clinically meaningful threshold 20%; 10% risk of control). Children in the intervention group had on average 2.29 less caries surfaces. The results are statistically significant, clinically meaningful but not precise (clinically meaningful threshold: 1 tooth surface difference).

Strengths

RCT design, appropriate randomization and allocation concealment, blinding of examiners, confounding control, intention-to-treat approach.

Limitations

Lack of blinding among providers and patients; there does not seem to be any bias in the numbers withdrawn by study group.

Applicability

The systematic review (SR) and the randomized controlled trial (RCT) participants were from the United States and Northern Ireland, respectively. Both participant pools were covered under some form of medicare, similar to the Quebec pediatric population under the age of 10 years. However, other factors must be taken into account, including the demographic’s SES, diet, education, environment, and water fluoridation status. Seeing as some of these factors do not align perfectly to the Quebec pediatric population, result applicability may be limited.

The interventions of both studies are feasible, as they don't require anything in addition to what is already available in the dental office, as long as appropriate oral health education and guidance provided. Since it was not possible to assess the clinical meaningfulness and precision of the results of the SR, their applicability into practice is questionable. The RCT intervention showed clinically meaningful results regarding the prevention of additional tooth surfaces from becoming cavitated, however the results are not precise and may not be clinically applicable. The time to follow-up of both studies falls within the range of 0 - 5 years, which satisfies our initial search criteria. The RCT presents an estimated mean cost of keeping one child caries-free over a 3-year period £2093, with £251 saved per avoided decay in a single tooth surface.

Similarly, the SR suggests that EPDVs are associated with more subsequent preventive dental visits, and may be associated with reduced restorative dental care visits and related expenditures during the first years of life. No adverse events are listed or anticipated for either the intervention or the control groups. Overall, the concept of a dental home is a sound measure, as it focuses on disease prevention at an early age, thus mitigating the need for future treatment. This concept by itself, however, is an area of research that would benefit from advancement.

Authors: Elena Aivaliklis, Constanta David, Stephanie Wiseman (DMD3 students)

Faculty mentor(s): Dr. Irwin Fried & Dr. Svetlana Tikhonova.

Acknowledgments: Martin Morris (librarian).

Date: March 24th , 2020

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