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JAMA Pediatrics study that finds no benefit of preventive dental care for some kids raises questions

February 27, 2017

By Michelle Manchir

The conclusions of a Feb. 27 online article in JAMA Pediatrics on early preventive dental care for children may have raised more questions than the researchers answered, some dental experts say.

Researchers reported no evidence of a benefit of early preventive dental care for children under 2 enrolled in Medicaid in Alabama.

The investigation concluded that it was "surprising" that preventive dental care from dentists appears to increase caries-related treatment.

The article's authors, Justin Blackburn, Ph.D.; Michael A. Morrisey; Ph.D.; and Bisakha Sen, Ph.D., pointed out the study's limitations, including the lack of information on community water fluoridation and on oral health behaviors such as tooth brushing and the indirect benefits of preventive dental care, such as improved quality of life.

The ADA and the American Academy of Pediatric Dentistry reaffirmed "their strong support for early dental visits to prevent childhood tooth decay" in a statement released March 1.

"As the authors state, this study design did not allow for evaluation of factors such as a genetic predisposition, previous disease and environmental considerations such as diet, frequency of brushing and flossing, the use of fluoride toothpaste and drinking fluoridated water, all of which are crucial in reducing the risk of cavities," said Dr. Mia L. Geisinger, associate professor, department of periodontology, University of Alabama at Birmingham and member of the ADA Council on Scientific Affairs, in the statement.

"Furthermore, there is no evaluation to determine if untreated cavities are present in those individuals who did not seek dental care for restorative treatment, so the data are incomplete," she said. "Because of this study's limitations, we cannot make any definitive conclusions from the data provided and further research is necessary. This study highlights the need to invest in oral health research to address the epidemic levels of tooth decay in some populations of children."

Added Dr. Paul Casamassimo, director of the American Academy of Pediatric Dentistry's pediatric oral health research and policy center, in the statement, "Studies of this nature are important in advancing our knowledge about early childhood cavities and their prevention and treatment, but these findings are not definitive, and further study is critical, in view of other findings supportive of early care and the epidemic nature of early childhood cavities."

The research article's authors used data from 2008 to 2012 to compare Alabama children under 2 years old who received early preventive dental care from a dentist or primary care provider with similar children who did not receive early preventive dental care.

They found that dentist-delivered preventive dental care was associated with an increase in the expected number of caries-related treatments, a higher rate of visits and higher annual dental expenditures.

In an editorial accompanying the research article, Drs. Peter Milgrom and Joana Cunha-Cruz wrote that while the investigation was "well executed" that "the most reasonable conclusion is that children with early tooth decay are identified early and subsequently are more likely to be referred for treatment at an earlier stage."

"Children who ended up at the dentist at those early ages who got some preventive treatments probably needed the care," Dr. Milgrom told the ADA News. "You can't conclude that these early visits to the dentist either do or don't prevent disease from these data."

Dr. Milgrom, director of the Seattle-based Northwest Center to Reduce Oral Health Disparities and a professor of dental public health sciences at the University of Washington, and Dr. Cunha-Cruz, a research associate professor at the University of Washington School of Dentistry, noted in their editorial about the study some important unstudied variables, especially the provision and effectiveness of anticipatory guidance regarding the use of fluoridated toothpaste and the restriction of sugary food and drinks.

The ADA Science Institute posted a Science in the News article in response to the research that notes while researchers used propensity score matching in analyzing the data, "this does not eliminate the chance that the children taken to see a dentist did not differ in some important way from the other children studied.  One possibility is that they may have had more overt caries disease to begin with. This would partially explain their subsequently greater caries-related visits and expenses."

The Science in the News analysis also said the article "strengthens the need for clinical trials to generate the data needed to determine best practices."

The American Dental Association, American Academy of Pediatric Dentistry and American Academy of Pediatrics recommend children see a dentist at least once before they are a year old. The ADA policy is stated in Resolution 90H-2014.

To read the JAMA Pediatrics study, click here. To read the full accompanying editorial, click here.