Fluoride Action Network


Background: Globally, children’s caries prevalence exceeds 30% and has not markedly changed in 30 years. School-based caries prevention programs can be an effective method to reduce caries prevalence, obviate traditional barriers to care, and use aerosol-free interventions. The objective of this study was to explore the clinical effectiveness of a comprehensive school-based, aerosol-free, caries prevention program.

Methods: The authors conducted a 6-year prospective open cohort study in 33 US public elementary schools, providing care to 6,927 children in communities with and without water fluoridation. After dental examinations, dental hygienists provided twice-yearly prophylaxis, glass ionomer sealants, glass ionomer interim therapeutic restorations, fluoride varnish, toothbrushes, fluoride toothpaste, oral hygiene instruction, and referral to community dentists as needed. The authors used generalized estimating equations to estimate the change in the prevalence of untreated caries over time.

Results: The prevalence of untreated caries decreased by more than 50%: from 39% through 18% in phase 1, and from 28% through 10% in phase 2. The per-visit adjusted odds ratio of untreated caries was 0.79 (95% confidence interval, 0.73 to 0.85).

Conclusions and practical implications: This school-based comprehensive caries prevention program was associated with substantial reductions in children’s untreated caries, supporting the concept of expanding traditional practices to include office- and community-based aerosol-free care.

*Original abstract online at https://jada.ada.org/article/S0002-8177(20)30842-4/fulltext



  1. Peres MA, Macpherson LMD, Weyant RJ, et al. Oral diseases: a global public health challenge. Lancet. 2019; 394: 249-260. PubMed.
  2. Centers for Medicaire & Medicaid Services. CMS national health expenditure data: age and gender. Also Google Scholar.
  3. American Dental Association Health Policy Institute. Supply and profile of dentists. Google Scholar.
  4. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999-2004 to 2011-2016. Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GA2019. Google Scholar.
  5. Center for Health and Health Care in Schools. School-based oral health services: a select bibliography.
  6. National Network for Oral Health Access. Survey of School-Based Oral Health Programs Operated by Health Centers: Descriptive Findings. National Network for Oral Health Access, Denver, CO2014. Google Scholar.
  7. Children’s Dental Health Project. Dental sealants: proven to prevent tooth decay. Google Scholar.
  8. Niederman R, Huang SS, Treschler AL, Listl S. Getting the incentives right: improving oral health equity with universal school-based caries prevention. Am J Public Health. 2017; 107: S50-S55. Google Scholar.
  9. Niederman R, Feres M, Ogunbodede E. Dentistry, in: 3rd ed. Essential Surgery: Disease Control Priorities. Vol. 1. World Bank Group, Washington, DC2015: 173-195. Google Scholar.
  10. Niederman R. Bringing care to people rather than people to care. Am J Public Health. 2015; 105: 1733. Google Scholar.
  11. Huang SS, Ruff RR, Niederman R. An economic evaluation of a comprehensive school-based caries prevention program. JDR Clin Trans Res. 2019; 4: 378-387. Google Scholar.
  12. von Elm E, Altman DG, Egger M, Pocock SJ, Getzsche PC, Vandenbrucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007; 147: 573-577. PubMed.
  13. Niederman R, Gould E, Soncini J, Tavares M. Osborn V, Goodson JM. A model for extending the reach of the traditional dental practice: the ForsythKids program. JADA. 2008; 139: 1040-1050. PubMed.
  14. US Department of Education. Title I: Improving the Academic Achievement of the Disadvantaged. US Government Printing Office, Washington DC 2020. Google Scholar.
  15. Watt RG, Daly B, Allison P, et al. Ending the neglect of global oral health: time for radical action. Lancet. 2019; 394: 261-272. PubMed.
  16. Huang SS, Niederman R. Economic evaluations of school sealant programs and the consent conundrum.. J Dent Res. 2019; 98: 145-147. Google Scholar.
  17. Wolfenden L, Kypri K, Freund M, Hodder R. Obtaining active parental consent for school-based research: a guide for researchers. Aust N Z J Public Health. 2009; 33: 270-275. PubMed.
  18. Esbensen FA, Melde C, Taylor TJ, Peterson D. Active parental consent in school-based research: how much is enough and how do we get it?. Eval Rev. 2008; 32: 335-362. PubMed.
  19. Dye BA,, Mitnik GL, Iafolla TJ, Vargas CM. Trends in dental caries in children and adolescents according to poverty status in the United States from 1999 through 2004 and from 2011 through 2014. JADA. 2017; 148: 550-565.e7. PubMed.
  20. Ruff RR, Niederman R. School-based caries prevention, tooth decay, and the community environment. JDR Clin Trans Res. 2018; 3: 180-187. Google Scholar.
  21. Cagetti MG, Bonta G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health. 2018; 18 (123). Google Scholar.
  22. Halasa-Rappel YA, Ng MW, Gaumer G, Banks DA. How useful are current caries risk assessment tools in informing the oral health care decision-making process?.JADA. 2019; 150: 91-102.e2. PubMed.
  23. Estai M, Kanagasingam Y, Tennant M, Bunt S. A systematic review of the research evidence for the benefits of teledentistry. J Telemed Telecare. 2018; 24: 147-156. Google Scholar.
  24. Beauchamp J, Caufield PW, Crall JJ, et al. American Dental Association Council on Scientific Affairs. Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. JADA. 2008; 139: 257-268. PubMed.
  25. Ricketts D, Lamont T, Innes NPT, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Syst Rev. 2013 Mar 28; : CD003808. PubMed.
  26. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press, Washington, DC2001. Google Scholar.
  27. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008; 27: 759-769. PubMed.
  28. Daubert v Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579 (1993). Google Scholar.
  29. Niederman R, Richards D, Brands W. The changing standard of care. JADA. 2012; 143: 434-437. PubMed.
  30. US Department of Labor, Occuptional Safety and Health Administration COVID-19: control and prevention: dentistry workers and employers.
  31. Zemouri C, de Soet H, Crielaard W,Laheij A. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS One. 2017; 12e0178007. PubMed.
  32. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020; 382: 1564-1567. PubMed.
  33. Gamio L. The workers who face the greatest coronavirus risk. New York Times.
  34. Benzian H, Niederman R. A dental response to the COVID-19 pandemic: Safer Aerosol-Free Emergent (SAFER) dentistry. Front Med (Lausanne). 2020; 7: 520. Google Scholar.
  35. Reinhardt UE. Priced Out: The Economic and Ethical Costs of American Health Care. Princeton University Press, Princeton, NJ2019. Google Scholar.
  36. Rogers EM. A prospective and retrospective look at the diffusion model. J Health Commun. 2004; 9: 13-19. PubMed.
  37. Langelier M, Baker B, Continelli. Development of a New Dental Hygiene Professional Practice Index by State. Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany, Rensselaer, NY2016. Google Scholar.
  38. Blackburn J, Morrisey MA, Sen B. Outcomes associated with early preventive dental care among medicaid-enrolled children in Alabama. JAMA Pediatr. 2017; 171: 335-341. PubMed.
  39. Capurro DA, Iafolla T, Kingman A, Chattopadhyay A, Garcia I. Trends in income-related inequality in untreated caries among children in the United States: findings from NHANES I, NHANES III, and NHANES 1999-2004. Community Dent Oral Epidemiol. 2015; 43: 500-510. PubMed.



Dr. Starr is the director of Strategic Initiatives, Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA; and a lecturer, Harvard School of Dental Medicine and the Harvard Medical School, Boston, MA.


Dr. Ruff is an associate professor, New York University College of Dentistry, New York, NY; and an associated professor, New York University School of Global Public Health, New York, NY.


Mr. Palmisano is the associate director, Data Management, Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA.


Dr. Goodson is a senior member of the staff, The Forsyth Institute, Cambridge, MA.


Dr. Bukhari is an assistant professor, Umm Alqura University, Faculty of Dentistry, Makkah, Saudi Arabia.


Dr. Niederman was a senior member of the staff, The Forsyth Institute, Cambridge, MA, when this article was written and now is a professor, New York University College of Dentistry, New York, NY.