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Task Force on Community Preventive Services. The Guide to Community Preventive Services. Atlanta (GA): Centers for Disease Control and Prevention; 1999-.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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The Guide to Community Preventive Services.

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A Comparison of Selected Evidence Reviews and Recommendations on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-related Craniofacial Injuries

, DMD, MPH, , MD, MPH, , PhD, , DDS, , MPH, MA, , PhD, , PhD, and , Jr, DDS, MPH.

Author Information

, DMD, MPH, , MD, MPH, , PhD, , DDS, , MPH, MA, , PhD, , PhD, and , Jr, DDS, MPH.*

From the Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion (Gooch, Griffin, Kohn); Office of the Director (Truman); and Division of Prevention Research and Analytic Methods, Epidemiology Program Office (Sulemana), Centers for Disease Control and Prevention, Atlanta, Georgia; Brevard College (Gift), Brevard, North Carolina; National Institute of Dental and Craniofacial Research (Horowitz, Evans), Bethesda, Maryland.
*Address correspondence and reprint requests to: Barbara F. Gooch, DMD, MPH, Dental Officer, Division of Oral Health, MS F-10, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA 30341. E-mail: vog.cdc@hcoogB

Published: 2002.

Medical Subject Headings (MeSH): cariostatic agents; community dentistry; community health planning; community health services; decision making; dental caries; evidence-based medicine; facial injuries; fluoridation; intervention studies; meta-analysis; mouth protectors; oral health; pharyngeal neoplasms; pit and fissure sealants; practice guidelines; preventive dentistry; preventive health services; public health dentistry; public health practice; review literature; tooth injury

Introduction

The reports in this supplement1,2 represent the work of the Task Force on Community Preventive Services (the Task Force), an independent, nonfederal group of national, regional, and local public health and prevention services experts supported by public and private partners. This report is one in a series of topics published as part of the Guide to Community Preventive Services (the Community Guide). Previously published topics include vaccine-preventable diseases, tobacco use and control, reducing injuries to motor vehicle occupants, diabetes, and physical activity. A full listing of published articles can be found at the website (www.thecommunityguide.org).

In addition to expanding the Community Guide, the reviews and evidence-based recommendations in this supplement1,2 add to the growing body of guidelines that identify and document the effectiveness of population-based interventions to promote oral health, as well as identifying areas in which high quality research on effectiveness is still needed. The Task Force reports complement other recent efforts that provide information and guidance to personnel in state and local health departments, purchasers of health care, people responsible for funding public health programs, policymakers, third-party payers, and others who have an interest in or responsibility for improving oral and related general health in all segments of the population. This article presents a summary of selected guidelines and evidence reviews available as of August 2001, and provides an accessible review of the current evidence of effectiveness of interventions related to those evaluated by the Task Force. These interventions address the prevention of dental caries (through community water fluoridation, school-based or school-linked pit and fissure sealant delivery programs, and statewide and community-wide sealant promotion programs), oral and pharyngeal cancers, and sports-related craniofacial injuries.

In this article we first describe the focus and general content of selected evidence reviews and guidelines, and the type of information contained in Tables 1 through 6. This is followed by a brief discussion of the comparisons across evidence reviews and guidelines for each oral health problem. The evidence of effectiveness is presented for two clinical interventions—sealant applications and soft-tissue examinations for oral and pharyngeal cancers and pre-cancers—that directly relate to the population-based interventions reviewed in the Community Guide. For prevention of sports-related craniofacial injuries, mandatory requirements for craniofacial protection in selected sports are also considered. The tables themselves are presented at the end of the article, organized by oral condition and intervention.

Table 1. Clinical application of dental sealants to the pit-and-fissure surfaces of teeth to reduce dental caries--Recommendations and summary effect measurements from selected guidelines and systematic reviews.

Table

Table 1. Clinical application of dental sealants to the pit-and-fissure surfaces of teeth to reduce dental caries--Recommendations and summary effect measurements from selected guidelines and systematic reviews.

Selected Evidence Reviews and Guidelines to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-related Craniofacial Injuries

The primary objective of this article is to compare the evidence reviews and recommendations from the Community Guide with reviews and recommendations recently produced by other major governmental and nongovernmental groups. Frequently-cited reports include the Centers for Disease Control and Prevention's (CDC) Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States 3 ; Oral Health in America: A Report of the Surgeon General 4 (SGR); Systematic Review of Water Fluoridation 5 (conducted by the National Health Service Centre for Reviews and Dissemination, University of York, England [NHS York Review]); Preventing and Controlling Oral and Pharyngeal Cancer: Recommendations from a National Strategic Planning Conference 6 ; and The Canadian Task Force on Preventive Health Care 7 (formerly Canadian Task Force on the Periodic Health Examination). Other evidence reviews and guidelines are included to provide additional sources for assessment of the strength of the evidence of effectiveness of an intervention, estimates of effectiveness, or a specific implementation recommendation from another agency or group.

This section identifies and briefly describes selected guidelines and evidence reviews included in this summary report. Methods for finding, evaluating, and summarizing the evidence of effectiveness varied among the different reporting groups, and are described below. After evaluating the evidence of effectiveness, some reporting groups provided summary effect measures (i.e., changes in outcome attributable to the intervention), some translated the evidence into recommendations on the basis of established rules, and others did both. As a result of these variations, the descriptions provided here cannot fully elaborate on the methods used or the target audience for each publication. In addition, several reviews (including the oral health section of the Community Guide, CDC's Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States, the SGR, and the Systematic Review of Water Fluoridation (NHS York Review) occurred concurrently and often in collaboration. To varying degrees these reviews shared the same literature and subject matter specialists.

The Guide to Community Preventive Services: Strategies to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-related Craniofacial Injuries (2002)

The oral health section of the Community Guide 1,2 includes evidence reviews on five interventions to promote oral health. Community Guide methods, which have been summarized elsewhere, 8 basically involve a systematic process of:

  1. identifying and selecting interventions to review;
  2. searching for published evidence (generally limited to studies published in English);
  3. abstracting and evaluating the quality of each identified study;
  4. summarizing the available body of evidence on effectiveness, other effects, applicability, economic evaluation, and barriers to implementation;
  5. translating evidence of effectiveness into recommendations, by using established rules; and
  6. identifying remaining questions for future research.

Methods specific to the oral health systematic reviews are summarized elsewhere in this supplement (see Truman et al., 2 Appendix A). In general, strength of evidence of effectiveness links directly to the strength of a recommendation. Evidence other than effectiveness can also be incorporated in Task Force recommendations. For example, evidence of harms resulting from an intervention might lead to a recommendation that the intervention not be used, even if it is effective in improving some outcomes. No oral health recommendation was so modified.

Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States (2001)

Because fluoride is now widely available from many sources, the Centers for Disease Control and Prevention (CDC) convened a workgroup in 1996 to develop recommendations for using fluoride to prevent and control dental caries in the United States. The report 3 includes "critical analysis of the scientific evidence regarding the efficacy and effectiveness of fluoride modalities in preventing and controlling dental caries, ordinal grading of the quality of the evidence, and assessment of the strength of each recommendation," primarily based on the evidence of effectiveness. Workgroup members collectively agreed on the quality of the evidence and strength of each recommendation. The recommendations address public health and professional practice, self-care, consumer product industries and health agencies, and needs for further research.

National Institutes of Health, Consensus Development Conference Statement, Diagnosis and Management of Dental Caries Throughout Life, March 26-28, 2001

National Institutes of Health (NIH) Consensus Statements are narrative summaries prepared by a nonadvocate, nonfederal panel of experts. The Consensus Statements are based on:

  1. presentations made during a one-and-a-half day public session by investigators working in areas relevant to the consensus questions,
  2. questions and statements from conference attendees during open discussion periods that are part of the public session, and
  3. closed deliberations by the panel during the remainder of the second day and morning of the third.

This conference, 9 sponsored by the National Institute of Dental and Craniofacial Research (NIDCR) and the NIH Office of Medical Application of Research, was convened to examine the current state of dental caries research to help healthcare providers and the general public make informed decisions. Cosponsors included the National Institute on Aging and the U.S. Food and Drug Administration. The best methods available for the prevention of dental caries initiation throughout life were among key questions addressed, and the evidence of effectiveness of pit and fissure sealants was examined.10,11 Presentations by investigators were based on systematic reviews of the dental research literature provided by the Agency for Healthcare Research and Quality. 12 An extensive bibliography of dental caries research articles was also prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience.

Oral Health in America: A Report of the Surgeon General (2000)

The major message of the first Surgeon General's report on oral health was that oral health is essential to general health and well-being and can be achieved by all people in the United States. However, all people are not achieving optimal oral health. The report 4 is a comprehensive narrative review of the published scientific literature about oral and craniofacial health and is presented in five parts:

  1. What is oral health?,
  2. What is the status of oral health in America?,
  3. What is the relationship between oral health and general health and well-being?,
  4. How is oral health promoted and maintained and how are oral diseases prevented?, and
  5. What are the needs and opportunities to enhance oral health?

In Part 4, the evidence for the efficacy and effectiveness of health promotion and disease prevention measures is reviewed with a focus on community efforts and on those conditions that pose the greatest burden to the U.S. population. Narrative reviews of the evidence of effectiveness are provided for most interventions, usually without a summary effect measure or a formal recommendation for use.

Systematic Review of Water Fluoridation (National Health Service Reviews, September 2000)

This evidence-based review of water fluoridation 5 had five objectives:

  1. Determine the effects of fluoridation of drinking water supplies on the incidence of caries;
  2. Determine the effect over and above that offered by the use of alternative interventions and strategies;
  3. Determine if fluoridation results in a reduction of caries across social groups and brings equity;
  4. Determine if fluoridation has negative effects; and
  5. Determine if the effect differs by natural and artificial water fluoridation.

This review involved a systematic process of:

  1. searching for evidence (25 electronic databases with no language restriction and the Internet),
  2. determining quality inclusion criteria,
  3. extracting data and assessing validity of studies;
  4. summarizing the available body of evidence of effectiveness and conclusions about original objectives,
  5. identifying limitations and implications for future research, and
  6. translating findings into information that can guide practice.

Where the data were in suitable format, summary measures of effect (range, median, and plots of 95% confidence intervals) were reported.

Benefits and Risks of Water Fluoridation: Report Prepared for Ontario's Public Consultation on Water Fluoridation Levels (November 1999)

This technical report 13 provided an update to the 1996 Canadian Federal-Provincial Subcommittee Report concerning fluoride in the water supply. 14 It included a systematic (1) search strategy (studies published between 1994 and 1999), (2) use of inclusion criteria, (3) assessment of study research design, (4) extraction process, (5) summary of the body of evidence on fluoridation's positive and negative effects (with range of fluoridation's beneficial and harmful effects stratified by study's country of origin), and (6) translation of the evidence into a qualified recommendation. Critical appraisal and interpretation of the literature and all recommendations were largely the work of one scientist.

Preventing and Controlling Oral and Pharyngeal Cancer: Recommendations from a National Strategic Planning Conference (1998)

In 1996, CDC convened a national conference to develop strategies for preventing and controlling oral and pharyngeal cancers in the United States. The conference was cosponsored by the NIDCR (formerly the National Institute of Dental Research) and the American Dental Association. Experts in oral and pharyngeal cancer prevention, treatment, and research developed recommendations in five areas 6 :

  1. advocacy, collaboration, and coalition building;
  2. public health policy;
  3. public education;
  4. professional education and practice; and
  5. data collection, evaluation, and research.

The recommendations included approaches successfully applied to other public health problems and were based on background papers—narrative summaries of the state of the science with regard to oral cancer prevention, control, and treatment—that drew on current literature reviews and the authors' critical analysis and expert opinion.

Institute of Medicine: Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride (1997)

"This is the initial report of a major new activity of the Food and Nutrition Board (FNB) of the Institute of Medicine: the development of a comprehensive set of reference values for dietary nutrient intakes for the healthy population in the United States and Canada." 15 Based on interaction with and information from expert panels and subcommittees, the Dietary Reference Intakes (DRI) Committee determined the DRI values included in this narrative report. The process included critical analysis of the scientific literature, evaluation of criteria of adequacy, provision of substantive rationales for each criterion, and review and application of risk assessment models for estimating levels of nutrients that may increase risk of toxicity or adverse effects (upper reference levels). "[T]he reference value that will be used for fluoride is Adequate Intake (AI). The AI is based on estimated intakes that have been shown to reduce the occurrence of dental caries maximally in a population without causing unwanted side effects including moderate dental fluorosis." 15

Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force (1996)

The U.S. Preventive Services Task Force (USPSTF) provides evidence-based recommendations for clinical practice about preventive interventions (e.g., screening tests for early detection of diseases, vaccinations, and counseling for risk reduction) for a wide variety of conditions. The main audience for the second edition of the Guide to Clinical Preventive Services 16 consisted of primary care physicians, nurse practitioners, and physician assistants. The USPSTF conducted evidence reviews using:

  1. a standardized search for evidence of effectiveness of clinical preventive services,
  2. standardized inclusion criteria, and
  3. standardized evaluations of the evidence concluding with a narrative review and a recommendation based on the strength of the evidence of effectiveness.

Workshop on Guidelines for Sealant Use: Recommendations. Association of State and Territorial Dental Directors (ASTDD), the New York State Health Department, the Ohio Department of Health, and the School of Public Health, University of Albany, State University of New York (1995)

An expert panel was convened in 1994 to revise earlier guidelines for sealant use in community and individual-care programs. 17 The publication 18 is an updated and expanded approach to determining which communities, individuals, teeth, and tooth surfaces are to receive sealants. The revisions were based on expert opinion, informed by available information on the epidemiology, clinical diagnosis, progression, and treatment of dental caries.

Canadian Task Force on Preventive Health Care (1994, with periodic updates)

The Canadian Task Force on Preventive Health Care (CTFPHC) uses a standardized methodology for evaluating the effectiveness of preventive healthcare interventions and for developing clinical practice guidelines primarily on the basis of evidence from published medical research. The explicit methodology includes:

  1. a standardized approach to evaluating the intervention (i.e., criteria of effectiveness),
  2. a standardized search for evidence of effectiveness,
  3. a standardized evaluation of the evidence of effectiveness, and
  4. development of practice recommendations based on the evidence of effectiveness viewed within the context of the clinical practice and healthcare settings to which the recommendations apply.

In 1994 a compilation of recommendations was published. 7 Since 1994, updates have been published primarily in the Canadian Medical Association Journal. Updates on prevention of dental caries 19 and prevention of oral cancer 20 are considered in this review.

Cochrane Collaboration (various reports)

The Cochrane Collaboration is an international coalition of participating researchers conducting systematic evidence reviews on a wide variety of clinical and public health topics. 21 No reviews on the effectiveness of any intervention directly related to those reviewed in the Community Guide to promote oral health had been published by August 2001, although protocols (introduction, objective, materials, and methods for reviews currently being prepared) have been developed for several related interventions, including pit and fissure sealants. The published reports will provide assessments of the effectiveness of interventions based on a systematic process including:

  1. a search for evidence (not usually restricted to the English language),
  2. standardized inclusion and exclusion criteria,
  3. standardized evaluation and abstraction of information,
  4. a pooled summary estimate using meta-analytic techniques when appropriate, and a narrative review when a pooled summary estimate could not be conducted, and
  5. a process of updating reviews as new evidence is identified.

Organization of the Summary Tables

Evidence reviews and recommendations are summarized in tables at the end of this article, arranged as follows:

  • Table 1: Clinical application of dental sealants to reduce dental caries
  • Table 2: Community interventions to reduce dental caries
  • Table 3: Clinical examinations for early detection of oral and pharyngeal cancers
  • Table 4: Community interventions to reduce oral and pharyngeal cancers
  • Table 5: Community interventions to encourage use of protective equipment to reduce craniofacial injuries in contact sports
  • Table 6: Use of craniofacial protective equipment mandated by major governing bodies in selected sports

Table 2 Community interventions to reduce dental caries—Recommendations and summary effect measurements from selected guidelines and systematic reviews.

Table

Table 2 Community interventions to reduce dental caries—Recommendations and summary effect measurements from selected guidelines and systematic reviews.

Table 3. Screening by clinical examination for early detection of oral and pharyngeal cancers—Recommendations from selected guidelines and systematic reviews.

Table

Table 3. Screening by clinical examination for early detection of oral and pharyngeal cancers—Recommendations from selected guidelines and systematic reviews.

Table 4. Population-based interventions for early detection of oral and pharyngeal pre-cancers and cancers (community-wide coordinated public education, professional education and training, professional examination of high-risk persons in various settings, and referral of persons with suspicious lesions)—Recommendations and summary effect measurements from selected guidelines and systematic reviews.

Table

Table 4. Population-based interventions for early detection of oral and pharyngeal pre-cancers and cancers (community-wide coordinated public education, professional education and training, professional examination of high-risk (more...)

Table 5. Population-based interventions to encourage use of protective equipment in contact sports: coordinated education about and promotion of the use of helmets, facemasks, and mouthguards to prevent sports-related traumatic injuries to the head, face, and mouth, directed to both players and the public--Recommendations and summary effect measurements from selected guidelines and systematic reviews.

Table

Table 5. Population-based interventions to encourage use of protective equipment in contact sports: coordinated education about and promotion of the use of helmets, facemasks, and mouthguards to prevent sports-related traumatic (more...)

Table 6. Use of craniofacial protective equipment a (helmet, facemask, mouthguard, and throat protector by position) mandated by governing bodies of selected sports.

Table

Table 6. Use of craniofacial protective equipment a (helmet, facemask, mouthguard, and throat protector by position) mandated by governing bodies of selected sports.

Summaries of the supporting evidence reviews are presented for each intervention. These include:

  1. a formal strength-of-evidence rating or recommendation, if provided;
  2. narrative conclusion, if any;
  3. summary effect measurements, if provided, with a brief description of the effect measure; and
  4. other pertinent information.

In Tables 1 and Table 3 the evidence of effectiveness is presented for clinical interventions (i.e., sealant applications and soft-tissue examinations for oral and pharyngeal cancers and pre-cancers) that directly relate to the evaluations of effectiveness of related community interventions reviewed in the Community Guide. Community interventions in Tables 2, 4, and 5 were reviewed in the Community Guide. Community interventions not evaluated in the Community Guide (e.g., school-based fluoride mouthrinse and tablet programs, public and professional education) are not presented in these tables.

Comparing Recommendations from Selected Guidelines

Four of the selected evidence reviews (the Community Guide; 2 Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States; 3 USPSTF; 16 and CTFPHC 7 ) present formal recommendations based on the evidence of effectiveness for each intervention. Three reviews (Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States; 3 USPSTF; 16 and CTFPHC 20 ) used the same evaluation criteria. One review, Systematic Review of Water Fluoridation (NHS York Review) 5 assessed the quality of the evidence on the positive and negative effects of community water fluoridation but did not offer a recommendation for or against implementing the intervention. In summarizing the conclusions from these reviews, the strength of evidence rating or recommendation is presented. In some cases, a brief quotation or statement is also presented. For several interventions, longer recommendation statements in the original document were abbreviated to fit the table format.

In all of the guidelines, readers were cautioned not to confuse an assessment of insufficient evidence of effectiveness with evidence of ineffectiveness, and that caution applies as well to the summaries presented here. In most cases, an assessment of insufficient evidence was based on an inadequate number of qualifying studies (i.e., studies meeting established criteria for study design and execution that allow reported changes in outcomes to be validly attributed to the intervention).

Guide to Community Preventive Services

Recommendations for or against use of an intervention were based on the evidence of effectiveness and consideration of other effects (positive and negative). The three options are:

  1. strongly recommended (for or against);
  2. recommended (for or against); and
  3. insufficient evidence (no recommendation for or against).

Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States; Guide to Clinical Preventive Services; The Canadian Task Force on Preventive Health Care

A letter rating was assigned to denote the strength of the evidence of effectiveness supporting the recommendation from both the USPSTF (although their approach was changed in 2001) and the CTFPHC for or against use of the intervention. Letter ratings range from A, "good evidence to support the recommendation to include " to E, "good evidence to support the recommendation to exclude." An evaluation of "insufficient evidence" is denoted by a letter rating of C.

Systematic Review of Water Fluoridation (NHS York Review)

Quality inclusion criteria were based on a predefined hierarchy of evidence: Level A, "highest quality of evidence with minimal risk of bias"; Level B, "evidence of moderate quality, moderate risk of bias"; and Level C, "lowest quality of evidence with high risk of bias."

Comparing Narrative Reviews from Selected Guidelines

Some of the selected guidelines provided a narrative evaluation of the evidence of effectiveness of the intervention. For presentation in the summary tables of this article, pertinent sections of the text were identified and quoted. In most cases, the included text represents an excerpt or quotation from an extended narrative evaluation of the studies providing evidence.

Comparing Summary Effect Measurements from Selected Guidelines

After evaluating the evidence of effectiveness of the intervention, three of the evidence reviews (Guide to Community Preventive Services; 2 Systematic Review of Water Fluoridation; 5 and Benefits and Risks of Water Fluoridation 13 ) provided summary effect measures. This information is provided in the tables with additional comments or information as needed. In all cases, the original document included a more detailed presentation and discussion of the summary effect measurements than is provided in this text or Tables 1 through Table 6.

Guide to Community Preventive Services

For community water fluoridation (CWF), before-and-after or post-exposure measures of dental caries prevalence were calculated at the tooth level. Summary effect measures included the range and median of (1) the absolute and relative change in dental caries, comparing the intervention group that started (or continued) fluoridation with the control group, and (2) the absolute and relative change in dental caries, comparing the intervention group that stopped fluoridation with controls. The summary effect measures for school-based and school-linked sealant delivery programs were the range and median of the percentage reduction in dental caries in the occlusal surfaces of posterior teeth between the control and the intervention groups, where dental sealants were delivered directly to children in school-based or school-linked settings.

Systematic Review of Water Fluoridation (NHS York Review)

Summary effect measures included the range and median of the absolute difference in the change in dental caries prevalence from baseline to the final examination between the control group (nonfluoridated areas) and the intervention group (fluoridated areas). Dental caries prevalence was measured at the tooth level and as the percentage of caries-free children. Only studies reporting before-and-after measures in concurrent comparison groups and variance data were used to calculate the effect measures.

Benefits and Risks of Water Fluoridation: Report Prepared for Ontario's Public Consultation on Water Fluoridation Levels

Summary effect measures included the range of absolute and percentage reductions in cumulative dental caries prevalence between control and intervention groups. Measures were presented for the primary and permanent teeth for each included study and aggregated by the countries in which the studies were undertaken. Effect measures in Table 2 are categorized into groups: countries with established market economies and those with developing market economies.

Cochrane Collaboration

Findings of systematic reviews had not yet been released at the time that the summary tables presented here were being prepared.

Discussion

Comparison of the systematic reviews and recommendations presented here reveals substantial agreement on both the effectiveness of community water fluoridation and school-based and school-linked sealant programs and the recommendations based on the strength of that evidence. All reviews indicate that the evidence of effectiveness of statewide or community-wide sealant promotion programs is very limited; insufficient to support a recommendation for or against their use, according to the Community Guide's rules. 8 For other interventions in which the evidence of effectiveness also was considered to be insufficient—interventions to reduce oral and pharyngeal cancers and to encourage use of craniofacial protective equipment in contact sports—different reviews reached different conclusions about the evidence and its implications for practice.

There was uniform agreement among recent reviews on the effectiveness of the clinical application of sealants to children's permanent molars in preventing decay, especially among children at high risk (Table 1). Consistent with the Community Guide's finding of strong evidence of effectiveness, the SGR 4 and the Workshop on Guidelines for Sealant Use 18 provide strong support for community sealant programs, such as school-based and school-linked programs (Table 2). Although the Community Guide strongly recommended school sealant programs, it found insufficient evidence to recommend for or against large-scale promotional activities directed towards practitioners, consumers, community leaders, and third-party payers. None of the other groups summarized effectiveness or made recommendations about the use of promotional activities, although the SGR and the Workshop on Guidelines for Sealant Use described such activities.

There was uniform agreement that CWF is effective in decreasing dental caries prevalence in communities (Table 2). The CDC's recommendations on use of fluorides, 3 SGR, 4 the Institute of Medicine, 15 and the CTFPHC 19 agreed with the Community Guide's strong recommendation for community water fluoridation. Two systematic reviews (Systematic Review of Water Fluoridation 5 (NHS York Review) and Benefits and Risks of Water Fluoridation 13 ) varied in the assessment of the strength of the evidence (e.g., moderate quality, limited quantity) but showed effect sizes that were similar to each other and to the Community Guide's findings. One of the reviews 13 concluded that the size of the effect was "small in absolute terms." CDC's recommendations on use of fluorides and the SGR also highlighted findings that fluoridation was cost-effective relative to other interventions to prevent dental caries. Their conclusions are consistent with the Community Guide's systematic review of the economic evaluations that reported fluoridation to be cost saving. CDC's recommendation on use of fluorides and the SGR also noted that fluoridation benefits all persons regardless of socioeconomic status or access to care. The Systematic Review of Water Fluoridation 5 (NHS York Review) found "some" evidence that fluoridation reduced inequalities in caries rates among children, across social classes (in England).

In the absence of data on the effectiveness of oral cancer examinations on health outcomes, the SGR, the USPSTF, and the CTFPHC found insufficient evidence to recommend for or against routine clinical screening (Table 3). All promoted consideration of oral examinations for people engaging in risk behaviors (tobacco use, regular alcohol consumption) or manifesting suspicious symptoms. The American Cancer Society 22 and the National Strategic Planning Conference on Preventing and Controlling Oral and Pharyngeal Cancer 6 recommended routine clinical examinations for asymptomatic people based on the rationale that such encounters provide opportunities for health counseling and case finding. The CTFPHC, however, noted that the usefulness of routine screening may be limited and the potential for false positive diagnoses increased when the incidence and prevalence of oral cancer is low.

The Community Guide, the SGR, and the CTFPHC agree that the evidence of effectiveness of population-based programs for early detection of pre-cancers and cancers, including screening of the general population, is insufficient (Table 4). Response to this lack of evidence varied, however. The Community Guide, consistent with its rules, did not make a recommendation for or against population-based approaches. The SGR highlighted the accessibility of the oral cavity for clinical and self-examination and the potential that heightened public awareness could increase examination rates and opportunities for provider determination of and advice about risk behaviors. The CTFPHC recommended excluding screening of the general population on the basis of the low prevalence and incidence of oral cancer in Canada and the potential for false positive diagnoses. The National Strategic Planning Conference on Preventing and Controlling Oral and Pharyngeal Cancer developed recommendations for population-based strategies addressing public advocacy, collaboration, and coalition building; public health policy and public education; professional education and practice; and data collection, evaluation, and research.

The Community Guide found insufficient evidence to recommend for or against interventions that encourage use of helmets, facemasks, and mouthguards in contact sports (Table 5). The SGR, policies and guidelines from selected medical and dental professional organizations, and mandatory rules of play from major governing bodies of organized sports (Table 6), however, all promote increased awareness and use of protective equipment in contact sports with risk of injury. These positions, policy statements, and mandatory rules are based on expert opinion and epidemiologic evidence about the risks of craniofacial injuries inherent to specific sports, and decreases in the occurrence of such injuries since mandatory requirements for craniofacial protection were implemented in certain sports, such as football and hockey.

Conclusion

This article has compared evidence reviews and recommendations by major governmental and nongovernmental groups that are primarily focused on selected population-based interventions to promote oral health. There was agreement that community water fluoridation and school-based and school-linked sealant programs are effective strategies to prevent dental caries. Several reviews noted that fluoridation can be cost saving and that it benefits all people regardless of socioeconomic status or access to care. There was also uniform agreement that clinical delivery of sealants to children's permanent molars is effective in preventing decay, especially among children at increased risk for dental caries. Consistent assessments of effectiveness and recommendations for use among various groups support initiation or increased use of these interventions in communities and healthcare systems when appropriate, based on local goals and resources.

For the other interventions reviewed in this report—community-wide sealant promotion programs to prevent dental caries, clinical oral cancer examinations, population-based interventions to reduce oral and pharyngeal cancers, and population-based interventions to encourage use of craniofacial protective equipment in contact sports—all systematic reviews found insufficient evidence of effectiveness or ineffectiveness. It should be noted again that a finding of insufficient evidence is not a recommendation for or against use of an intervention, but rather a reflection both of the lack of qualifying studies on which to base a recommendation and of the need for more and better research on intervention effectiveness. In the absence of evidence that meets current standards for effectiveness, research some organizations based recommendations for action on other factors, described briefly in this report. Until research findings become available, state and local health departments, funders of public health programs, and policy and other decision makers can judge the usefulness of these interventions based on other criteria and approaches.

Acknowledgments

We thank the following individuals for their contributions to this comparative review: Lisa Barrios, Centers for Disease Control and Prevention (CDC), Christine Bolger, National Association for Sport & Physical Education; Peter Briss, CDC; Jerry Diehl, National Federation of State High School Associations; Julie Gilchrist, CDC; Kate W. Harris, CDC; John Klyop, American Dental Association; Jim Lyznicki, American Medical Association; Dolores Malvitz, CDC; Brenda Mazzocchi, CDC; and Jan Stansell, CDC. We are also indebted to those who created the reports, guidelines, and mandatory rules of play that we examined in these comparisons.

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