Policy on School-Entrance Oral Health Examinations

Purpose

The American Academy of Pediatric Dentistry (AAPD) encourages policy makers, public health and education officials, and medical and dental communities to recognize that unmet oral health needs can impact a child’s ability to learn. An oral health examination prior to matriculation into school may improve school readiness by providing a timely opportunity for prevention, diagnosis, and treatment of oral conditions. 

Methods

This policy was developed by the Council on Clinical Affairs, adopted in 2003¹ , and last revised in 2017² . This revision included electronic database and hand searches of articles in the medical and dental literature using the terms: oral health examination, dental screening, dental examination, dental assessment, school oral health examinations, dental certificates AND school-entrance; fields: all; limits: within the last 10 years, humans, English, birth through age 18. Additionally, reports on oral health in American^3,4 and websites for the American Academy of Pediatrics and the AAPD were reviewed.

Background

Professional care is necessary to maintain oral health.^3,4 The AAPD “emphasizes the importance of initiating professional oral health intervention in infancy and continuing through adolescence and beyond. The periodicity of professional oral health intervention and services is based on a patient’s individual needs and risk indicators.”⁵ The American Academy of Pediatrics recommends that, beginning at age three, a child’s comprehensive health assessment should include attention to problems that might influence school achievement.^6,7 Many states mandate general health examinations prior to school entrance. However, integration of general health and oral health care programs remains deficient.⁸ While regulations may not guarantee that every child will be examined by a dentist, they do increase the likelihood of this happening.⁹

Caries is the most common chronic disease of childhood in the United States (U.S.).³ Early childhood caries (ECC) is a severe problem for young children nationwide, with approximately 23 percent of children aged two through five years having experienced caries in the primary dentition, and 10 percent having untreated disease.^10,11 By six to eight years of age, the prevalence of dental caries increases to 56 percent.^10,11

Poverty remains one of the most important indicators of early childhood dental caries experience, with about one in three preschoolers living in poverty having some form of ECC.⁴ Dental care remains as one of the greatest unmet needs for children. Untreated health conditions such as asthma, dental pain, and vision and hearing deficits are leading causes of chronic absence, and children with oral health problems are three times more likely than their peers to miss school.^10,12 Safe and effective measures exist to prevent caries and periodontal diseases; however, dissemination and awareness of such measures do not reach the population at large.⁴ More than one-fourth of the U.S. population does not benefit from community water fluoridation.¹³ Because the use of fluoride contributes to the prevention, inhibition, and reversal of caries,13 early determination of a child’s systemic and topical fluoride exposure is important. A dental home provides the necessary diagnostic, preventive, and therapeutic practices, as well as ongoing risk assessment and education, to improve and maintain the oral health of infants, children, and adolescents.¹⁴ To maximize effectiveness, the dental home should be established within six months of eruption of a child’s first tooth and no later than the child’s first birthday.¹⁴

The public’s lack of awareness of the importance of oral health is a major barrier to dental care.^3,4 Oral health is integral to general health.^3,4 Oral conditions can interfere with eating and adequate nutritional intake, speaking, self-esteem, and daily activities.¹⁵ Children with untreated disease may be severely underweight because of associated pain and the disinclination to eat. Nutritional deficiencies during childhood can impact cognitive development.¹⁶ Rampant caries is one of the factors causing insufficient development in children who have no other medical problems.¹⁷ Unrecognized disease and postponed care result in exacerbated problems, which lead to more extensive and costly treatment needs.

Health and education are closely related.¹⁸ Children with dental pain may be irritable, withdrawn, or unable to concentrate. Pain can affect test performance as well as school attendance.^15,16 Data from the North Carolina Child Health Assessment and Monitoring Program showed that children with poor oral health status were nearly three times more likely to miss school as a result of dental pain than were their counterparts.¹⁹ In addition, absences caused by pain were associated with poorer school performance.¹⁹ Further analysis demonstrated that oral health status was associated with performance independent of absence related to pain.¹⁸

Following a report by the U.S. Surgeon General,³ the Centers for Disease Control and Prevention launched the Oral Health Program Strategic Plan for 2011-2014.²⁰ This campaign aimed to provide leadership to prevent and control oral diseases at national level. The program helped individual states strengthen their oral health promotion and disease prevention programs. However, requirements for oral health examinations, implementation/enforcement of regulations, and administrative disposition of collected data vary both among and within states.²⁰ As of 2019, 14 states and the District of Columbia had a dental screening law, and another state (Connecticut) had legislation in process.⁹ Although dental screening laws are used to help ensure that children’s oral health does not impede their ability to learn, these laws also present an opportunity to connect children in need with a dental home.⁹

Policy statement

Early detection and management of oral conditions can improve a child’s oral health, general health and well-being, and school readiness. Recognizing the relationship between oral health and education, the AAPD:

• advocates legislation requiring a comprehensive oral health examination by a qualified dentist for every student prior to matriculation into school. The examination should be performed in sufficient detail to provide meaningful information to a consulting dentist and/or public health officials. This would include documentation of oral health history, soft tissue health/pathologic conditions, oral hygiene level, variations from a normal eruption/ exfoliation pattern, dental dysmorphology or discoloration, dental caries (including noncavitated lesions), and existing restorations. The examination also should provide an educational experience for both the child and the parent. The child/parent dyad should be made aware of age-related caries-risk and caries-protective factors, as well as the benefits of a dental home.
• recognizes that without requiring, tracking, and funding appropriate follow-up care, requiring oral health examinations is insufficient to ensure school readiness and, therefore, advocates such legislation to include subsequent comprehensive oral examinations at periodic intervals throughout the educational process because a child’s risk for developing dental disease changes and oral diseases are cumulative and progressive.
• encourages local leaders to establish a referral system to help parents obtain needed oral health care and establish a dental home for their children.
• encourages state and local public health and education officials, along with other stakeholders such as health care providers and dental/medical organizations, to document oral health needs, to work toward improved oral health and school readiness for all children, and to address related issues such as barriers to oral health care.
• opposes regulations that would prevent a child from attending school due to noncompliance with required examinations.
• encourages its members and the dental community at large to volunteer in programs for school-entry dental examinations to benefit the oral and general health of the pediatric community.