Policy on Oral Health Care Programs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes the importance of education, prevention, diagnosis, and treatment necessary to optimize the oral health of infants, children, adolescents, and individuals with special health care needs through preventive and restorative care. Comprehensive health care cannot be achieved unless oral care is included in all health service programs. 

Methods

This policy was developed by the Dental Care Programs Committee and adopted in 1972.¹ This document is an update of the 2020 revision² by the Council on Clinical Affairs. This revision is based upon a review of current publications and websites of governmental agencies and health care organizations. A PubMed®/MEDLINE search was performed using the terms: oral health policy, infant oral health, child oral health policy, adolescent oral health; oral health special healthcare needs; fields: all; limits: within the last 10 years, humans, English, birth through age 18. One thousand five-hundred nineteen articles matched these criteria. Papers for review were chosen from this list and from references within selected articles. When data did not appear sufficient or were inconclusive, policies were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Background

The United States Department of Health and Human Services (HSS) reported caries to be the most prevalent chronic childhood disease in our nation’s children.³ The prevalence of dental caries in two-to-five-year-old children in the 2016 National Health and Nutrition Examination Survey (NHANES) was noted to be 23.3 percent; little improvement had been made compared to previous years.⁴ Children from low income families were twice as likely to experience decay in this age group compare to their higher-income counterparts.^4,5 In 2019, dental care was reported as the greatest unmet healthcare need for children ages two to six years and six to 17 years.⁶ During the coronavirus disease 2019 (COVID-19) pandemic, many parents either elected not to seek preventive care or were unable to access preventive care, further decreasing oral health care utilization among children.⁷

Strategies are needed to meet the needs of children and families and effectively address early childhood caries (ECC).⁸ Primary care medical providers have frequent contact with families, providing opportunities to incorporate oral health promotion and prevention in nondental settings. They can accomplish an oral screening, caries-risk assessment, oral health counseling, and application of fluoride varnish.⁸ Since 2014, the U.S. Preventive Task Force has recommended primary healthcare providers apply fluoride varnish to infants and children, regardless of risk assessment, as soon as the first teeth emerge.⁹ Pediatricians increasingly have become involved with oral healthcare and perceive it as an integral part of a child’s overall health.¹⁰ Increasing pediatrician involvement in oral health has led to an increased number of pediatricians applying fluoride varnish during preventive care visits: three percent in 2008 compared to 19 percent in 2018. Pediatricians also provided oral health assessments for 79 percent of their patients.¹⁰ The Centers for Disease Control and Prevention has cooperative agreements at the state and national levels to improve oral health outcomes such as decreasing the prevalence of dental caries, oral health disparities, and chronic diseases associated with oral health comorbidities.¹¹ Some initiatives include school-based sealant programs, community water fluoridation, oral health surveillance programs (e.g., NHANES), medicaldental integration programs (e.g., pediatrician-directed fluoride varnish application), and Head Start (HS) programs.¹¹

HS is a federal program that promotes school readiness for low-income families.¹² Early childhood programs such as HS or Early Head Start have obligatory standards for health promotion to include oral health.¹³ Comprehensive oral health standards are provided by the American Academy of Pediatrics, the American Public Health Association, and the Office of Head Start.¹³ According to the U.S. Department of Health and Human Services (HHS) Head Start Program Performance Standards Related to Oral Health, “a program must promote effective oral health hygiene by ensuring all children with teeth are assisted by appropriate staff, or volunteers, if available, in brushing their teeth with toothpaste containing fluoride once daily.”¹⁴ This federal standard is the minimum for each state as it administers its respective HS programs. Participation in HS programs has a positive effect on the use of dental services and oral health related quality of life.¹⁵

Another example of a successful oral health program is school-based sealant programs for low-income children.¹⁶ Providing sealants in such programs has been found to save 485 fillings per 1000 children and is highly cost-effective.¹⁷ According to a split-mouth design study of first permanent molars, school-based sealant programs have been found to have a 67 percent risk reduction of developing new caries lesions compared to those who had not received a sealant.¹⁸

By raising oral health awareness, the prevention, early detection, and management of dental, oral, and craniofacial tissues can become integrated into general health care, communitybased programs, and social services.³ HHS recognizes that oral health can have a significant impact on overall health and well-being. Major statements of the Oral Health in America: Advances and Challenges¹⁹ include:

• “Good oral health supports overall health”;
• “some groups experience more disease and more barriers to care than the general population”; and
• “Lack of access to regular dental care can result in ineffective and expensive overuse of emergency departments.”

Oral health integration into the broader health care system is still viewed as a supplemental benefit, not a priority benefit.²⁰ This separate view of oral health negatively impacts our nation including the increasing use of emergency departments at substantial cost to treat dental pain and related conditions.²⁰

The HHS report National Call to Action to Promote Oral Health²¹ included a partnership of public and private organizations that specified a vision, goals, and a series of actions to promote oral health, prevent disease, and reduce oral health disparities in vulnerable populations including the disadvantaged poor, racial and ethnic groups, individuals living in geographically isolated areas, and those with special oral health care needs. These actions are necessary and define certain tasks to assure that all Americans of all ages and those individuals who require specialized health care services, interventions, and programs achieve optimal oral health. The Call to Action urges that oral health promotion, disease prevention, and oral health care issues have a presence in all health policy agendas and are discussed at local, state, and national levels.²¹ Its success relies on shared knowledge and its execution at all levels.²¹

The HHS created the U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014-2017 (known as The Framework) which reflects deliberations and next steps proposed by HHS and other federal partners to support the department’s oral health vision and eliminate oral health disparities.22 The Framework has five goals:

1. “Integrate oral health and primary health care.
2. Prevent disease and promote oral health.
3. Increase access to oral health care and eliminate disparities.
4. Increase the dissemination of oral health information and improve health literacy.
5. Advance oral health in public policy and research.”²²

Policy statement

The AAPD advocates that oral health care must be included in the design and provision of individual, community-based, and national health care programs to achieve comprehensive health care. This can be achieved through the recommendations of the HHS reports Oral Health Initiative 2010²³ and U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014-2017 ²².