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Not So Fast on Dental Screenings in Primary Care, USPSTF Says

Routine screenings for signs of cavities and gum disease by primary care clinicians may not catch patients most at risk of these conditions, according to a statement by the US Preventive Services Task Force (USPSTF) that was published in JAMA on November 7.

Suggesting ways to improve oral health also may fail to engage the patients who most need the message, the group said in its statement.

The task force is not suggesting that primary care providers stop all oral health screening of adults or that they never discuss ways to improve oral health. But the current evidence of the most effective oral health screenings or enhancement strategies in primary care settings received an “I” rating, for “Inconclusive.” The highest ranking a screening can receive is an “A” or “B,” which indicate that there is strong evidence for conducting a screening, while a “C” would indicate that clinicians could rarely provide a screening, and a “D” would indicate not to, given the current evidence.

Primary care clinicians should immediately refer any patients with apparent caries or gum disease to a dentist, the USPSTF noted. But what clinicians should do for patients who have no obvious oral health problems is up for debate.

“The ‘I’ is a note about where the evidence is at this point, and then a call for more research to see if we can’t get some more clarity for next time,” said John Ruiz, PhD, professor of clinical psychology at the University of Arizona in Tucson, who is a member of the task force.

More than 90% of US adults may have caries, including 26% with untreated caries that can cause serious infections or tooth loss. In addition, 42% of adults have some type of gum disease. More than two thirds of Americans aged 65 or older have gum disease, and it is the leading cause of tooth loss in this population. People earning low incomes and those who do not have health insurance or who belong to a marginalized racial or ethnic group are at greater risk of the harms of caries and gum disease.

“Oral health care is important to overall health,” and any new research on oral health screening and enhancement efforts should be demographically representative of adults affected by these conditions, Ruiz said.

In an accompanying editorial, oral health researchers from the National Institutes of Health and the University of California, San Francisco, echoed the call for representative research and encouraged closer collaboration between primary care providers and dentists to promote oral health.

“Oral health screening and referral by medical primary care clinicians can help ensure that individuals get to the dental chair to receive needed interventions that can benefit both oral and potentially overall health,” the authors wrote. “Likewise, medical challenges and oral mucosal manifestations of chronic health conditions detected at a dental visit should result in medical referral, allowing prompt evaluation and treatment.”

Lack of Data

The USPSTF defined oral health screenings for patients older than 18 who have no obvious signs of caries or gum disease as looking at a patient’s mouth during physical exams. Additionally, clinicians might use prediction models to identify patients at greater risk of facing these problems.

Strategies to improve oral health include providing encouragement to patients to reduce intake of refined sugar, to floss and brush effectively to reduce bacteria, and to use fluoride gels, fluoride varnishes, or other kinds of sealants to make caries harder to form.

A literature review found that there has been limited analysis of primary care clinicians performing these tasks. Perhaps unsurprisingly, more such studies about dentists existed, leaving an open field for dedicated studies about what primary care clinicians should do to optimize oral health with patients.

“Clinicians, in the absence of clear guidelines, should continue to use their best judgment,” Ruiz said.

One dentist who spoke to Medscape Medical News said screening could be as simple as doctors asking patients how often they brush their teeth and giving patients a toothbrush as part of the office visit.

“It all comes down to, Is the person brushing their teeth?” said Jennifer Hartshorn, DDS, who specializes in community and preventive dentistry at the University of Iowa in Iowa City.

“By all means look in their mouth, ask how much they are brushing, and urge them to find a dental home if at all possible,” Hartshorn said, especially for patients who smoke or have conditions such as dry mouth, which can increase the risk of oral disease.

Ruiz and Hartshorn report no relevant financial relationships.

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