FL: Fluoride Exposure in the US (2010)

Bader JD, Rozier RG, Lohr KN, Frame PS. Physicians’ roles in preventing dental caries in preschool children: A summary of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med. 2004; 26(4): 315-325.


Study Design:
Meta-analysis or Systematic Review
M - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To review the evidence for the effectiveness of primary care clinician-based interventions to prevent dental caries in preschool children.

Inclusion Criteria:

Literature search of MEDLINE articles written in English language between 1966 and October 2001 were reviewed for relevance to key questions.  Also, studies identified in the Cochrane Controlled Trials Register were added.

Exclusion Criteria:

Articles were excluded if they did not relate to one of the key questions.

Description of Study Protocol:


Literature search through MEDLINE and Cochrane controlled Trials Register.


Literature was reviewed for its pertinence to any of the following key questions:

  • Accuracy of screening: How accurate is screening by the primary care clinician in identifying children aged from birth to five years who:
    • Have dental caries requiring referral to a dentist
    • Are at elevated risk for future dental caries
  • Referral to a dentist: How effective is referral by the primary care clinician of children aged from birth to five years to a dentist in terms of the proportion of referred children making a dental visit
  • Fluoride supplementation and enamel fluorosis: How effective is the prescription of dietary supplemental fluoride by the primary care clinician in terms of:
    • Appropriateness of supplementation decision
    • Parental adherence to the dosage regimen
    • Prevention of dental caries
  • Professional fluoride application: How effective is application of fluoride by the primary care clinician in terms of:
    • Appropriateness of application decision
    • Achieving parental agreement for the application
    • Prevention of dental caries
  • Counseling for caries prevention behaviors: How effective is counseling by the primary care clinician for caries-preventive barriers, as measured by:
    • Adherence to the desired behavior
    • Prevention of dental caries.

Statistical Analysis

This systemic review of literature did not allow for statistical comparison of data.

Data Collection Summary:

Timing of Measurements

Literature review of research available from 1966 to 2001.

Dependent Variables

  • Accuracy of screening
  • Referral to a dentist
  • Fluoride supplementation
  • Fluoride supplements and enamel fluorosis
  • Professional fluoride application
  • Counseling for caries prevention behaviors.

Independent Variables

  • Response rates
  • Type of Physician (Pediatrician vs. Family)
  • Age of subjects
  • Knowledge level.

Control Variables

Geographic location (level of fluoride in environment).

Description of Actual Data Sample:

Initial and Attrition N

  • Accuracy of screening: 118 articles identified, 12 reviewed, two included in this report
  • Referral to a dentist: 102 articles identified, 12 reviewed, one included
  • Fluoride supplementation: 12 identified, 10 reviewed and included
  • Professional fluoride application: Zero identified, six experimental studies on the effectiveness of fluoride varnish discussed
  • Counseling for caries prevention behaviors: 140 articles identified, 20 reviewed, one included.


Subjects were generally birth to five years old though some reviews included physician and parent responses, opinions and actions.

Other relevant demographics

Geographic location was indicated in some studies relating to fluoride exposures. 


Studies were written in English but included data from United States, Sweden, China, Taiwan and Poland.


Summary of Results:

Of the five questions addressed in this review, the following was relevant: How effective is the prescription of dietary supplemental fluoride by the primary care clinician in terms of: 

  • Appropriateness of supplementation decision
  • Parental adherence to the dosage regimen
  • Prevention of dental caries.

Key Findings

  • The strength of evidence relating to the accuracy and effectiveness of primary care clinicians' identification and referral relating to dental health is poor, primarily due to small sample sizes of physician practices
  • The strength of evidence relating to the appropriateness of fluoride supplementation is fair due to the consistency of data reported although the data was primarily self-reported, older and thus less valid
  • The strength of evidence relating to the effectiveness of fluoride supplementation is fair, also due to consistent, but likely less valid, data
  • The strength of evidence supporting the effectiveness of fluoride varnish in the prevention of dental caries is fair
  • The strength of the evidence for the effectiveness of counseling is poor. 

Fluoride Supplementation

Based on 10 studies included, the authors concluded:

  • Physicians were not perfectly informed about community and individual fluoridation status. This could lead to inappropriate supplementation decisions, e.g., in two studies, 69% and 74% of pediatricians and 26% and 58% of family practitioners were aware of the fluoridation status in their practice area.
  • 56% to 71% of physicians practicing in cities with fluoridated water reported prescribing supplements
  • No eligible studies were identified regarding the question of the level of parental adherence with the daily dosage regimen
  • Across studies, use of supplements was consistently associated with reductions in the number of teeth with caries (32% to 72% reduction for primary teeth) and tooth surfaces with caries lesions (38% to 81% for primary tooth surfaces).


Author Conclusion:

The evidence base for recommendations to physicians relating to the prevention of dental caries in young children needs to be strengthened. The authors echo the recommendation of the National Institutes of Health Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life, "more and higher-quality comprehensive longitudinal multi-factor studies of implicated risk indicators are needed to obtain firm support for their associations with caries incidence to clarify the strengths of these associations in differing populations, and to reveal the extent to which the indicators provide independent, as opposed to redundant, information" (pp. 10-11).

Funding Source:
University/Hospital: University of North Carolina at Chapel Hill
Other: Not reported
Reviewer Comments:

Funding for individual studies is not provided. Unclear of funding for the review as well.

Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? Yes
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? No
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? Yes
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? No
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? No
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes