Policy on Oral Health Care Programs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs
The American Academy of Pediatric Dentistry (AAPD) recognizes the importance of education, prevention, diagnosis, and treatment necessary to maintain 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.
This policy was developed by the Dental Care Programs Committee and adopted in 1972.1 This document is an update of the previous version, revised in 2016.2 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 policy, child oral health policy, adolescent oral health policy; oral health for special needs; fields: all; limits: within the last 10 years, humans, English, birth through age 18. Six hundred thirty-six articles matched these criteria. Papers for review were chosen from this list and from references within selected articles.
The U.S. Department of Health and Human Services (HSS) reports that caries is the most prevalent chronic childhood disease in our nation’s children.3 Early childhood caries affects children’s quality of life and their ability to learn and concentrate in school.4-6 Although the AAPD7, American Academy of Pediatrics8, and the American Dental Association9 recommend establishment of a dental home by 12 months of age, referral patterns by primary care providers are inconsistent with this recommendation.10-13 Only nine percent of Medicaid-enrolled children aged one-two years received preventive dental services in 2008.14 More than 40 percent of children have caries by the time they reach kindergarten.15 In contrast to declining prevalence of dental caries among children in older age groups, the prevalence of caries in poor U.S. children under the age of five is increasing.16 Studies demonstrated caries prevalence within the two to five year old age group from higher income families was 18 percent while that of children from low-income families was 42 percent.17,18 Disparities in caries prevalence exist within specific population subgroups in the U.S.19-22 From 2011-2014, 12.4 million children below the age of 19 in the United States had untreated caries.23 Socioeconomic and demographic differences are cited as barriers for treatment.23
Researchers used the 2016-2017 National Survey of Children’s Health to analyze a link between oral health status and academic performance.24 Assessing data from more than 45,000 six-17 year olds, they found poor oral health was strongly linked to poor academic performance and missed school days.24 This association was consistent across subpopulations defined by age, gender, household income, and type of health insurance coverage.24
New strategies are needed to meet the needs of children and families and effectively address early childhood caries (ECC).18 Primary care medical providers have frequent contact with families, providing opportunities to incorporate oral health promotion and prevention in non-dental settings. They can accomplish an oral screening, risk assessment, oral health counseling, and application of fluoride varnish.18 Key findings from the National Health and Nutrition Examination Survey (NHANES) include:
- “For 2015–2016, prevalence of total caries (untreated and treated) was 45.8 percent and untreated caries was 13.0 percent among youth aged two-19 years.
- Prevalence was lowest in youth aged two–five years compared with those aged six-11 and 12–19 for total (21.4 percent, 50.5 percent, 53.8 percent) and untreated
caries (8.8 percent, 15.3 percent, 13.4 percent).
- Hispanic youth had the highest prevalence of total caries; non-Hispanic black youth had the highest prevalence of untreated caries.
- For both total and untreated caries, prevalence decreased as family income level increased.
- Untreated caries prevalence increased from 2011–2012 (16.1 percent) to 2013–2014 (18.0 percent) and then decreased in 2015–2016 (13.0 percent).”25
Untreated caries among children two–eight years of age was shown to be twice as high for Hispanic and non-Hispanic African American children in comparison to non-Hispanic white children.19 American Indian (AI) and Alaska Native (AN) children demonstrated a higher rate of caries than other population groups in the U.S., with approximately 40 percent of AI/AN children aged one–five years exhibiting untreated caries in contrast to only 11 percent of non-Hispanic white children.21
HHS reports a perception that oral health is separate from general health and, therefore, less important.3 By raising oral health awareness, the prevention, early detection, and management of dental, oral, and craniofacial tissues can become integrated into general health care, community-based programs, and social services.3 HHS recognizes that oral health can have a significant impact on overall health and well-being. Major themes of the Oral Health in America: A Report of the Surgeon General 3 include:
- "Oral health means much more than healthy teeth."
- "Oral health is integral to general health."
Oral health integration into the broader health care system is still viewed as a supplemental benefit, not a priority benefit.26 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.26
Accordingly, the HHS report National Call to Action to Promote Oral Health27 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 five principal actions and implementation strategies that constitute the Call to Action include:
- “Action 1–Change Perceptions of Oral Health-Policymakers, community leaders, private industry, health professionals, the media, and the public are called upon to raise the level of awareness and understanding of oral health, affirming that oral health is essential to general health and well-being.
- Action 2–Overcome Barriers by Replicating Effective Programs and Proven Efforts-Remove known barriers between people and oral health services by implementing strategies to engage all groups to eliminate health disparities through health promotion and health literacy, improve access.
- Action 3–Build the Science Base and Accelerate Science Transfer-Application of research findings to improve oral health.
- Action 4–Increase Oral Health Workforce Diversity, Capacity, and Flexibility-Ensure the adequacy of public and private health personnel and resources to meet the oral health needs of all Americans and enable the integration of oral health effectively with general health.
- Action 5–Increase Collaborations-Develop partnerships and utilize resources from social services, education, health care services at state and local levels, including community groups, voluntary organizations and individuals.”27
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.27 Its success relies on shared knowledge and
its execution at all levels.27
As follow-up to Oral Health in America3, the HHS Oral Health Initiative 2010 was developed.28 The key statement from this initiative was, “Oral health is integral to overall health”.28 Total health and wellness cannot exist without oral health. Oral disease can have an impact on physical, psychological, social, and economic health and well-being through pain, diminished function, and reduced quality of life.29 Through this initiative, programs were created, produced, and financed to:
- emphasize oral health promotion and disease prevention.
- increase access to care.
- enhance oral health workforce.
- eliminate oral health disparities.13
The HHS created the 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.30 The Framework has five goals:
- “Integrate oral health and primary health care.
- Prevent disease and promote oral health.
- Increase access to oral health care and eliminate disparities.
- Increase the dissemination of oral health information and improve health literacy.
- Advance oral health in public policy and research.”30
Federal agencies currently collaborate and through communication processes ensure that comprehensive, updated, evidence-based health information is disseminated.30 Government agencies and providers continue to engage, develop and implement solutions to improve overall health and well-being.30
The Institute of Medicine (IOM) in 2009 evaluated the oral health system for the entire U.S. population and provided recommendations and strategic approaches to the HHS for a potential oral health initiative.31 Reviewing important factors such as care settings, workforce, financing, quality assessments, access to care, and education, the IOM committee focused on these areas and how these factors linked to current and future HHS programs and policies.12 The committee report, Advancing Oral Health in America32, provided recommendations/organizing principles for a new oral health initiative:
- establish HHS high-level accountability in evaluating the oral health initiative.
- focusing on disease prevention and oral health promotion.
- improving oral health literacy and cultural competence.
- reducing oral health disparities.
- enhancing the delivery of oral health care.
- enhance the role of non-dental health care professionals.
- expand oral health research and improve data collection.
- promote collaboration among private and public stakeholders.
- measure progress toward short-term and long-term goals and objectives.
- advance the goals and objectives of Healthy People 202013.
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 201028 and U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014-201730.
1. American Academy of Pedodontics. Oral health care programs for children and adolescents. Chicago, Ill.: American Academy of Pedodontics; 1972.
2. American Academy of Pediatric Dentistry. Oral health care programs for infants, children, and adolescents. Pediatr Dent 2016;38(special issue):23-4.
3. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
4. Abanto J, Carvalho TS, Mendes FM, Wanderley MT, Bonecker M, Raggio DP. Impact of oral diseases and disorders on oral health-related quality of life of preschool children. Community Dent Oral Epidemiol 2011;39(2):105-14.
5. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children’s school attendance and performance. Am J Public Health 2011;101(10):1900-6.
6. Martins-Júnior PA, Vieira-Ansdrade RG, Corrêa-Faria P, Oliveira-Ferreira F, Marques LS, Ramos-Jorge ML. Impact of early childhood caries on the oral health-related quality of life of preschool children and their parents. Caries Res 2013;47(3):211-8.
7. American Academy of Pediatric Dentistry. Policy on dental home. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020;43-4.
8. American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics 2014;134(6):1224-9. Reaffirmed January, 2019.
9. American Academy of Pediatric Dentistry Foundation, Dental Trade Alliance Foundation, American Dental Association. The Dental Home: It’s Never Too Early to Start February, 2007. Available at: “https://www.aapd.org/assets/1/7/DentalHomeNeverTooEarly.pdf ”. Accessed August 16, 2020.
10. Brickhouse TH, Unkel JH, Kancitis I, Best AM, Davis RD. Infant oral health care: A survey of general dentists, pediatric dentists, and pediatricians in Virginia. Pediatr Dent 2008;30(2):147-53.
11. Chay PL, Nair R, Tong HJ. Pediatricians’ self-efficacy affects frequency of giving oral health advice, conducting oral examination, and prescribing referrals. J Dent Child 2019;86(3):131-8.
12. Zhu Y, Close K, Zeldin L, Quiñonez RB, White BA, Rozier RG. A clinical vignette-based study of physicians’ adherence to guidelines for dental referrals of young children. Acad Pediatr 2019;19(2):195-202.
13. Zhu Y, Close K, Zeldin LP, White BA, Rozier RG. Implementation of oral health screening and referral guidelines in primary health care. JDR Clin Trans Res 2019;4(2):167-77.
14. Bouchery E. Utilization of dental services among Medicaid-enrolled children. Medicare Medicaid Res Rev 2013;3(3):E1-E14. Available at: “https://www.cms.gov/mmrr/Downloads/MMRR2013_003_03_b04.pdf ”. Accessed September 9, 2020.
15. Pierce KM, Rozier RG, Vann WF Jr. Accuracy of pediatric care providers’ screening and referral for early childhood caries. Pediatrics 2002;109(5):E82-2.
16. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Vital Health Stat 2007;11(248):1-92.
17. Dye BA, Arevalo O, Vargas CM. Trends in paediatric dental caries by poverty status in the United States, 1988-1994 and 1999-2004. Int J Paediatr Dent 2010;20(2):132-43.
18. Douglass JM, Clark MB. Integrating oral health into overall health care to prevent early childhood caries: Need, evidence, and solutions. Pediatr Dent 2015;37(3):266-74.
19. Dye BA, Hsu KL, Afful J. Prevalence and measurement of dental caries in young children. Pediatr Dent 2015;37(3):200-16.
20. Garcia R, Borrelli B, Vineet D, et al. Progress in early childhood caries and opportunities in research, policy, and clinical management. Pediatr Dent 2015;37(3):294-9.
21. Phipps KR, Ricks TL. The oral health of American Indian and Alaska Native children aged 1-5 years: Results of the 2014 IHS oral health survey. Indian Health Service Data Brief. Rocksville, Md.: Indian Health Service; 2015. Available at: “http://www.ihs.gov/doh/ documents/IHS_Data_Brief_1-5_Year-Old.pdf ”. Accessed August 16, 2020.
22. Ricks TL, Phipps KR, Bruerd B. The Indian Health Service early childhood caries collaborative: A 5-year summary. Pediatr Dent 2015;37(3):275-80.
23. Gupta N, Vujici M, Yarbrough C, Harrison B. Disparities in untreated caries among children and adults in the U.S., 2011-2014. BMC Oral Health 2018;18:30. Available at: “https://bmcoralhealth.biomedcentral.com/track/pdf/10.1186/s12903-018-0493-7”. Accessed September 9, 2020.
24. Guarnizo-Herreño CC, Lyu W, Wehby GL. Children’s oral health and academic performance: Evidence of a persisting relationship over the last decade in the United States. J Pediatr 2019;209:183-9.e2. Available at: “https://www.jpeds.com/article/S0022-3476(19)30135-0/fulltext”. Accessed September 9, 2020.
25. Fleming E, Afful J. Prevalence of total and untreated dental caries among youth: United States, 2015-2016. NCHS Data Brief, no 307. Hyattsville, Md.: National Center for Health Statistics; 2018:1-7. Available at: “https://www.cdc.gov/nchs/data/databriefs/db307.pdf ”. Accessed November 11, 2020.
26. Tabak LA, U.S. Department of Health and Human Services National Institutes of Health. Notice to announce commission of a Surgeon General’s report on oral health. Federal Registry 2018;83(145):1. Available at: “https://www.govinfo.gov/content/pkg/FR-2018-07-27/pdf/2018-16096.pdf”. Accessed September 9, 2020.
27. Office of the Surgeon General (US). National Call To Action To Promote Oral Health. Rockville, Md.: National Institute of Dental and Craniofacial Research (US); 2003. Available at: “https://www.ncbi.nlm.nih.gov/books/NBK47472/”. Accessed September 9, 2020.
28. U.S. Department of Health and Human Services. Oral Health Initiative 2010. Rocksville, Md.: U.S. Department of Health and Human Services, Health Resources and Services Administration; 2010. Available at: “https://www.hrsa.gov/sites/default/files/oralhealth/hhsinitiative.pdf ”. Accessed August 16, 2019.
29. Murthy VH. Surgeon General’s Perspectives. Oral Health in America, 2000 to Present: Progress made, but challenges remain. Public Health Rep 2016;131(2):224-5. Available at: “https://journals.sagepub.com/doi/pdf/10.1177/003335491613100202”. Accessed August 16, 2020.
30. U.S. Department of Health and Human Services Oral Health Coordinating Committee. U.S. Department of Health and Human Services Oral Health Strategic Framework, 2014-2017. Public Health Rep 2016;131(2):242-57. Available at: “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765973/”. Accessed November 13, 2020.
31. Institute of Medicine. 2009. Informing the Future: Critical Issues in Health, Fifth Edition. Washington, D.C.: The National Academies Press. “https://doi.org/10.17226/12709”. Accessed November 11, 2020.
32. Institute of Medicine. Advancing Oral Health in America. Washington, D.C.: The National Academies Press; 2011. Available at: “https://www.hrsa.gov/sites/default/files/publichealth/clinical/oralhealth/advancingoralhealth.pdf ”. Accessed November 11, 2020.