Policy on Oral Health in Child Care Centers

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that one out of three preschool age children receives care in a child care center.¹  The expectation is that this policy will provide guidance to the child care centers, pediatric dentists, other health care professionals, legislators, and policy makers regarding oral health activities and oral health promotion in out-of-home child care settings.

Methods

This policy was developed by the Council of Clinical Affairs, adopted in 2011², and last revised in 2016³. The revision is based upon a review of current dental and medical literature, including a search of the PubMed®/MEDLINE database using the terms: oral health care guidelines in child care centers, child daycare centers and dental health, dental guidelines and daycare centers, and dental care in child day care centers; fields: all; limits: within the last 10 years, humans, English, birth through age 18. Thirty-five articles matched these criteria. Papers for review were chosen from this list and from the 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. Documents of health care and public policy organizations, state statutes, and regulations relating to the concept of oral health in child care centers also were reviewed. 

Background

In the United States (U.S.) in 2019, 59 percent of children ages zero through five who were not enrolled in kindergarten received some form of child care arrangement on a regular basis from persons other than their parents.¹ Fifty-five to 65 percent of these children attended center-based programs which include day care centers, pre-kindergartens, nursery schools, Head Start programs, and other early childhood education programs.¹

Parents, directors of child care centers, and health professionals recognize that enhancing health promotion education in child care could improve child health.⁴ Addressing the oral health needs of infants and young children as early as possible and as a part of well-child care is critical since dental disease is preventable. A majority of states address oral health in their child care licensing regulations.^5-8 However, states’ oral health regulations in early education and child care center programs often do not provide comprehensive oral health policies and practices.⁷ Some oral health practices have been found to vary between centers serving children of lower socioeconomic status and those providing care to higher socioeconomic status children.⁸ Research found non-statefunded centers were more inclined to implement oral health practices than state-funded facilities.⁸ A higher percentage of state-funded child care centers reported tooth brushing as a routine activity in the classroom, whereas more non-state funded centers reported implementing numerous oral health practices as well as an educational practice focusing on oral health.⁸ A survey of directors of licensed child care centers (95 percent not affiliated with Head Start) determined the greatest perceived barriers to carrying out oral health promotion practices were insufficient funding, insufficient staff training, and insufficient time.⁹

Effective oral health care requires collaboration between families, early care and educational professionals, and health care professionals. Collaboration has the potential to improve the breadth and effectiveness of health promotion education⁴ and enhance the opportunity for a child to have a lifetime free from preventable oral disease. Many organizations have requirements and recommendations that apply to out-ofhome child care and can serve as valuable resources regarding health promotion in child care centers. These include the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education along with National Association for the Education of Young Children (NAEYC), and Head Start.^10-13

Establishment of a dental home by 12 months of age ensures awareness of age-specific oral health issues with long term positive effects for the children.¹⁴ Caries is a significant public health problem affecting preschool children.15 It is the most common chronic disease of childhood, affecting 21.4 percent of children two to five years of age.¹⁶ The prevalence of total (treated and untreated) caries rises to 50.5 percent of children aged six through 11 years old.¹⁶ Epidemiologic data from a 2015-2016 national survey clearly indicates that early childhood caries (ECC) remains highly prevalent in poor and near-poor U.S. preschool children.¹⁶ Low-income children are affected disproportionately, being twice as likely as children from higher-income families to have decay in primary teeth.17 In 2019, dental care was reported as the greatest unmet healthcare need for children ages two to six years and six to 17 years.¹⁸

Policy statement

The AAPD encourages child care centers, early education providers, and parents to implement preventive practices that can decrease a child’s risk of developing ECC.¹⁴ The AAPD recognizes that increasing health promotion in out-of-home child care settings could improve the oral health of millions of preschool-age children. Therefore, the AAPD encourages child care centers to:

• utilize oral health consultation, preferably by a pediatric dentist, at least once a year and as needed. The health consultant should review and observe program practices regarding oral health and make individualized recommendations for each program.
• promote the concept of the dental home by educating their personnel, as well as the parents, on the importance of oral health and providing assistance with establishment of a dental home no later than 12 months of age of the child.
• maintain a dental record, starting at age 12 months with yearly updates, as part of the child’s health report. It should address the child’s oral health needs including any special instructions provided to the caregivers.
• have written, up-to-date, comprehensive procedures to prepare for, report, and respond to medical and dental emergencies (including pain/toothache). The source of urgent care should be known to caregivers and acceptable to parents.
• sponsor on-site, age-appropriate oral health education programs for the children that will promote good oral hygiene and dietary practices, injury prevention, and the importance of regularly scheduled dental visits.
• provide in-service training programs for personnel regarding oral hygiene concepts, proper nutrition choices, link between diet and tooth decay, prevention of ECC, and children’s oral health issues including proper initial response to traumatic injuries along with dental consequences. Personnel with an understanding of these concepts are at a great advantage in caring for children.
• encourage parents to be active partners in their children’s health care process and provide an individualized education plan, one that is sensitive to cultural values and beliefs, to meet every family’s needs. Written material should be available and, at a minimum, address oral health promotion and disease prevention and the timing of dental visits.
• familiarize parents with the use of and rationale for oral health procedures administered through the program and obtain advance parental authorization for such procedures.
• incorporate an oral health assessment as part of the daily health check of each child.
• promote supervised or assisted oral hygiene practices at least once daily after a meal or a snack.
• provide well-balanced and nutrient-dense diets of low caries-risk.¹⁹
• have clean, optimally-fluoridated drinking water available for consumption throughout the day.¹⁹
• not permit infants and toddlers to have bottles/sippy cups in the crib or to carry them while walking or crawling while under the child care center’s supervision.
• minimize saliva-sharing activities (e.g., sharing utensils, orally cleansing a pacifier) to help decrease an infant’s or toddler’s acquisition of cariogenic microbes.²⁰
• consider implementation of comprehensive oral health practices when legislative regulations are limited or nonexistent.⁸