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Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Adults: A Systematic Review for the U.S. Preventive Services Task Force

Evidence Synthesis, No. 233

Investigators: , MD, , MD, MPH, , MPH, , MSc, CIC, , BA, , MS, and , DDS, MPH, PhD.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 23-05305-EF-1

Structured Abstract


Dental caries and periodontal disease are common oral health conditions in adults. In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians counsel patients to prevent dental and periodontal disease; however, the USPSTF noted insufficient evidence on the effectiveness of counseling for changing oral health behaviors.


To systematically review the evidence on primary care screening for and prevention of dental caries and periodontal disease in adults.

Data Sources:

We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, and MEDLINE to October 3, 2022, and manually reviewed reference lists; with surveillance through July 21, 2023.

Study Selection:

Studies on diagnostic accuracy of primary care screening instruments and oral examination; randomized controlled trials (RCTs) and non-randomized trials of screening and preventive interventions; cohort studies on risk of fluorosis with fluoride preventive interventions; and cohort studies of oral health screening in primary care.

Data Extraction:

One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the USPSTF.

Data Synthesis (Results):

Sixteen studies (reported in 17 publications) were included in this update (five RCTs, five non-randomized trials, and six observational studies; total 3,300 participants). One poor-quality trial (n=477) found no difference between oral health screening of pregnant persons versus no screening on caries burden, severity of periodontal disease, or birth outcomes. One study (n=86) found primary care oral health exam associated with low sensitivity (0.42 and 0.56, based on two examiners) and high specificity (0.84 and 0.87) for periodontal disease, and variable sensitivity (0.33 and 0.83) and high specificity (0.80 and 0.93) for dental caries. Four studies (N=965) found a screening questionnaire associated with a pooled sensitivity of 0.72 (95% confidence interval [CI] 0.57 to 0.83) and specificity of 0.74 (95% CI 0.66 to 0.82) for periodontal disease. No trial evaluated the effectiveness of primary care oral health behavioral counseling versus no counseling or referral by a primary care clinician to a dental health provider versus no referral. Evidence from two poor-quality trials (N=178) of sealants and one fair-quality and four poor-quality trials (N=971) of topical fluorides (varnish or gels/solution) was insufficient to determine preventive effectiveness of these interventions. Three fair-quality trials (N=590) of silver diamine fluoride (SDF) in older adults (mean age 72 to 80 years) found SDF solution associated with decreased risk of new root caries lesions or fillings versus placebo (mean reduction ranged from −0.33 to −1.3) and decreased likelihood of having a new root caries lesions (two trials, adjusted odds ratio 0.4, 95% CI 0.3 to 0.7 and relative risk 0.19, 95% CI 0.07 to 0.46). Evidence on harms of screening, counseling, or referral was not available; reporting of harms of preventive interventions was very poor, though serious harms were not reported.


Oral health preventive interventions were administered by dental professionals with uncertain applicability and feasibility in primary care; only English-language articles were included; sparse or no evidence on screening and preventive interventions; most studies of preventive interventions had serious methodological limitations; screening questionnaires included items on prior periodontal disease, potentially reducing applicability to screening; uncertain generalizability of older studies or studies conducted in resource-poor settings to current U.S. practice.


SDF solution improved root caries outcomes in older adults when administered by dental professionals. Screening questionnaires were associated with moderate diagnostic accuracy for periodontal disease; evidence on the accuracy of the primary care oral health exam was limited and estimates varied. Research is needed to determine benefits and harms of screening, primary care counseling, dental referral, and oral health preventive interventions administered in primary care settings.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857; www.ahrq.gov Contract No. 75Q80120D00006, Task Order No. 75Q80121F32009 Prepared by: Pacific Northwest Evidence-Based Practice Center, Oregon Health & Science University, Mail Code: BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239, www.ohsu.edu/epc

Suggested citation:

Chou R, Selph S, Bougatsos C, Nix C, Ahmed A, Griffin J, Schwarz E. Screening, Referral, Behavioral Counseling, and Preventive Interventions for Oral Health in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 233. AHRQ Publication No. 23-05305-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2023.

This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00006, Task Order No. 75Q80121F32009). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.

Bookshelf ID: NBK597289PMID: 37972224


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