School dental screening for oral health

Dental caries persists as a common chronic disease of childhood affecting significant numbers of children worldwide presenting an important public health problem. School dental screening to identify children with oral health problems and bring these children into contact with oral health services has been in place in many countries. In 2006 the UK National Screening Committee noted that there was no evidence to support the effectiveness of school-based dental screening in increasing dental attendance rates or reducing caries levels for children a decision it confirmed at its most recent review in 2019.

The aim of this Cochrane review was to update their review assessing the effectiveness of school dental screening programmes on overall oral health status and use of dental services.

Methods

Searches were conducted in the Cochrane Oral Health’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform databases with no restrictions on date or language. Cluster or parallel randomised controlled trials (RCTs) evaluating school dental screening compared with no intervention or another type of screening were considered. The usual Cochrane methodological process were followed.

Results

8 RCTs (6 cluster RCTs) with 21,290 children aged 4 to 15 years.
4 RCTs were conducted in the UK, 2 in India one in Saudi Arabia and one in the USA.
2 RCTs were considered to be at low risk of bias, 3 at high risk and 3 at unclear risk.
Outcomes were assessed at 3 – 11 months.
4 trials evaluated traditional screening versus no screening. Meta-analysis for the outcome ‘dental attendance’ an found an inconclusive result with high heterogeneity [very low certainty evidence].
2 cluster-RCTs (both four-arm trials) evaluated criteria-based screening versus no screening, suggesting a possible small benefit. pooled risk ratio (RR) = 1.07 (95%CI; 0.99 to1.1) [low-certainty evidence]. When comparing criteria-based screening to traditional screening there was no evidence of a difference RR = 1.01 (95%CI; 0.94 to 1.08) [very low-certainty evidence].
1 trial compared a specific (personalised) referral letter to a non-specific letter. Results favoured the specific referral letter for increasing attendance
at general dentist services RR= 1.39 (95%CI; 1.09 to 1.77) [very low-certainty evidence] and attendance at specialist orthodontist services RR = 1.90 (95%CI; 1.18 to 3.06) [very low-certainty evidence].
1 trial compared screening supplemented with motivation to screening alone. With dental attendance being more likely after screening with motivation RR = 3.08 (95%CI; 2.57 to 3.71) [very low-certainty evidence].
1 trial compared referral to a specific dental treatment facility with advice to attend a dentist.
There was no evidence of a difference in dental these two referrals RR = 0.91 (95%CI; 0.34 to 2.47) [very low-certainty evidence].
Only one trial reported the proportion of children with treated dental caries. This trial evaluated a post-screening referral letter based on the common-sense model of self-regulation (a theoretical framework that explains how people understand and respond to threats to their health), with or without a dental information guide, compared to a standard referral letter. The findings were inconclusive. [very low-certainty evidence].

Conclusions

The authors concluded: –

The evidence is insufficient to draw conclusions about whether there is a role for school dental screening in improving dental attendance.

We are uncertain whether traditional screening is better than no screening (very low-certainty evidence). Criteria-based screening may improve dental attendance when compared to no screening (low-certainty evidence). However, when compared to traditional screening, there is no evidence of a difference in dental attendance (very low-certainty evidence).

For children requiring treatment, personalised or specific referral letters may improve dental attendance when compared to non-specific referral letters (very low-certainty evidence). Screening supplemented with motivation (oral health education and offer of free treatment) may improve dental attendance in comparison to screening alone (very low-certainty evidence). We are uncertain whether a referral letter based on the ‘common-sense model of self-regulation’ is better than a standard referral letter (very low-certainty evidence) or whether specific referral to a dental treatment facility is better than a generic advice letter to visit the dentist (very low-certainty evidence).

The trials included in this review evaluated effects of school dental screening in the short term. None of them evaluated its effectiveness for improving oral health or addressed possible adverse effects or costs.

Comments

This Cochrane review updates the 2019 version (Dental Elf – 12^th Aug 2019) adding in one additional trial bringing the total to 8 RCTs. However as with the 2019 update the additional data has not changes the conclusions. The reviewers highlight that the outcomes assessed included dental attendance, proportion of children with untreated/treated dental caries, and caries and but not other untreated oral health needs, developmental dental defects, orthodontic need cost effectiveness or adverse events.

The reviewers call for standardisation of the definitions related to school dental screening and for future clinical trials to follow the CONSORT group guidelines to improve conduct and reporting. They also call for trials in middle- and low-income countries and the inclusion of different forms of screening and motivational factors, assessment of caries and other oral diseases measured over a longer period.

The UK National Screening Committee with be reviewing their decision in 2022-23

Links

Primary Paper

Arora A, Kumbargere Nagraj S, Khattri S, Ismail NM, Eachempati P. School dental screening programmes for oral health. Cochrane Database Syst Rev. 2022 Jul 27;7:CD012595. doi: 10.1002/14651858.CD012595.pub4. PMID: 35894680.

The Dental Elf