Policy on Care for Vulnerable Populations in a Pediatric Dental Setting

Purpose

The American Academy of Pediatric Dentistry (AAPD) is committed to the improvement of healthcare for all children and adolescents, regardless of their race, ethnicity, religion, sexual or gender identity, medical status, family structure, or financial circumstances. Additionally, the AAPD is committed to increased access to dental services and improved oral health for all children and adolescents, including those from vulnerable and underserved communities. The intent of this document is to increase awareness of vulnerable populations and the challenges they face in achieving optimal oral health as well as to advocate for culturally-safe care¹ and improved access to dental services

Methods

This policy was developed by the Council on Clinical Affairs and adopted in 2020. ² This update is based on a review of current dental and medical literature, including search of the PubMed® database with the following terms: evidence based dentistry [MeSH] OR dentistry [MeSH]) AND (vulnerable populations [MeSH] OR special health care needs [Tiab] OR sexual and gender minorities [MeSH] OR gender diverse [Tiab] OR lgbtq [Tiab] OR homeless youth [MeSH] OR child, foster [MeSH] OR military children [Tiab] OR immigrant children [Tiab] OR incarcerated youth [Tiab] OR mental health [MeSH]; limits: within the last 10 years, human, English. This resulted in 296 articles of which 27 were reviews or systematic reviews. Papers for review were chosen from this list and from references within selected articles.

Background

Vulnerable populations are communities at increased risk of health problems and health disparities for many reasons including geography, finances, medical status, age, and societal discrimination.^3,4 Such vulnerability may be temporary or permanent, and status may be improved or exacerbated by social and economic policies at the state and federal levels. Negative health sequelae of limited access to care among vulnerable populations include disproportionately poor oral and systemic health status and lower utilization rates of preventive services.^5-7

Socioeconomic factors (eg, poverty) and their intersection with other social and structural determinants (eg, racism, insurance eligibility) significantly impact children’s oral health and consequent oral health disparities.^8,9 An increased awareness of vulnerable populations and the challenges they face may help inform oral health care professionals’ approach to patient care. These groups include lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and otherwise identified (LGBTQIA+) youth, military-connected families, homeless youth, those in the foster care system, youth in juvenile detention systems, youth with mental health disorders, individuals with special health care needs(SHCN), Indigenous peoples, children affected by armed conflicts, and immigrants. This list is by no means comprehensive, and future revisions to this policy will continue to include updated discussion of populations at risk for poorer oral health due to sociopolitical, economic, and environmental vulnerabilities.

Many pediatric dentists take active roles in their communities as advocates for children’s health. Awareness of social determinants of oral health⁹ and culturally-safe approaches to patient care can result in higher quality delivery of dental services. Oral health care professionals may seek out resources that would benefit their patients as individuals and as a community and develop networks to aid vulnerable populations in obtaining needed health and social services.

Youth in the juvenile justice system
Adolescents who have passed through the juvenile justice system constitute a vulnerable population due to higher rates of health risky behaviors, limited access to healthcare, and sociodemographic factors. In 2020, over 400000 arrests were made of youth younger than age 18. ¹⁰ The number of youth in residential placement varies, but recent census data reports more than 24000 juveniles may be assigned to residential placement on any given day.¹¹ Lack of housing stability, disruptions in education, and other sequelae of poverty correlate with higher rates of arrests among youth from low socioeconomic backgrounds.¹² Incarcerated youth have higher rates of health risky behaviors, particularly in the realm of mental and sexual health.^13,14

The oral health of youth in juvenile detention centers may be compromised by a lack of comprehensive treatment and continuity of care and concomitant health risky behaviors. Although recent studies on the oral health of incarcerated youth are lacking, significantly higher rates of untreated decay and low rates of preventive measures among incarcerated compared to non-incarcerated youth have been reported.(Bolin 2006) Urgent dental problems including infection, tooth and jaw fractures, and severe periodontal disease were found in over 6% of the subjects included in one study.¹⁵

Health care professionals may have implicit biases toward youth in custody that can delay diagnosis or treatment.¹⁶ Challenges in caring for youth in detention facilities include scheduling appointments, security concerns, transportation considerations, lack of legal guardian’s involvement, and availability of providers. ¹⁶

Awareness of these barriers to care can aid oral health care professionals when coordinating treatment for incarcerated youth. Connecting patients to other healthcare services within the facility, particularly when oral manifestations of systemic diseases are recognized in youth who have not yet been evaluated by a physician, may be necessary. ¹⁴ Ideally, efforts to establish a dental home and reinstate insurance coverage would be made prior to release from the facility.

Once released from detention facilities, juveniles may face hardships establishing care and preventive services due to lack of family involvement and external support, difficulties adjusting to their previous environment, problems accessing previous health care medical records, and challenges in obtaining insurance coverage.¹² Connecting with social services in their communities can facilitate ongoing care for previously incarcerated youth.

Children with mental health conditions or behavioral disorders
One out of every 5 children in the US has been diagnosed with a mental health disorder. ¹⁷ Mental health conditions vary in terms of cause, incidence, and severity. The most commonly diagnosed mental health conditions in children are attention deficit hyperactivity disorder (ADHD), anxiety, behavior problems, and depression.¹⁸ According to recent US data, approximately 6 million children under the age of 18 have been diagnosed with ADHD, 5.8 million with anxiety, and 2.7 million with depression.¹⁷ In 2018-2019, over 50% of children ages 3 through 17 diagnosed with a mental health condition received treatment for their disorder.¹⁸ Worldwide, people with mental health disorders may be subject to social stigmatization and discrimination, higher rates of physical and sexual violence, and limitations to their participation in civic life and public affairs. Their ability to access essential health care and social services, including emergency services, may be challenging.¹⁹

People with behavioral or mental health conditions are susceptible to worsened oral health.²⁰ Those with depressive disorders may experience fatigue and lack of motivation for self-care that impedes proper home oral hygiene. Anxiety or depression can lead to lower self-esteem and dental fears that make one less likely to seek professional dental care.²¹ Such risk factors may lead to increased rates of dental decay and tooth loss, which in turn exacerbate mental health conditions by contributing to social withdrawal, low selfesteem, and difficulty with functions such as eating and speaking.²⁰ Children and adolescents with ADHD may be prone to dental injuries and bruxism habits.^22-25 Xerostomia is a known side effect of multiple psychotropic medications.²⁰ Patients at risk for xerostomia may benefit from education on proper fluoride use and increased frequency of water intake. Eating disorders may start in childhood and more commonly in adolescence and have the highest rate of mortality of any mental health condition.²⁶ Eating disorders can result in detrimental oral health behaviors with consequences including severe erosion of enamel and increased risk of dental caries. ²⁷ Awareness of intraoral signs of eating disorders allows oral health care professionals to be prepared to discuss concerns with patients and their families.

The patient’s mental health condition, including psychiatric management, and behavior modification strategies,^28,29 medications,^30,31 and home hygiene practices, is an important consideration for oral health care professionals. Connections with mental health provider networks can facilitate counseling service referrals of patients with mental health concerns that have not yet been addressed by a mental health professional.³²

Individuals with special health care needs
Individuals with SHCN are among the many vulnerable populations who suffer profound health disparities.33-36 Those who treat individuals with SHCN need specialized knowledge, training, awareness, and willingness to accommodate patients beyond routine measures.³⁷ Studies regarding utilization rates of preventive dental services by children with SHCN compared to those without SHCN have been mixed. 38 Nonetheless, dental care continues to be one of the most common unmet healthcare need among this population.^33-35,38-42 In fact, low-income children with the most severe healthcare conditions are more likely to have unmet dental needs.^34,43 Individuals with SHCN face many barriers to obtaining adequate oral health care including competing medical priorities, difficulties finding a knowledgeable and willing oral health care professional, residing in rural locations, transportation issues, inadequate insurance, and caregivers factors such as depression, low levels of functioning, and financial burdens of caring for an individual with SHCN.^33-36,44,45 Addressing financial, geographic, and social barriers have been identified as strategies to address oral health disparities experienced by children with SHCN.³⁹ An integral part of the specialty of pediatric dentistry is to provide comprehensive preventive and therapeutic oral health care to individuals with SHCN.⁴⁶ Failure to accommodate patients with SHCN could be considered discrimination and a violation of federal and/or state law.⁴⁷ Therefore, when the treatment needs of an individual with SHCN are beyond the scope of practice of the oral health care professional, referral to a practitioner who is comfortable, knowledgeable, and appropriately trained to manage the patient’s individual oral health care needs is indicated. ⁴⁸

LGBTQIA+ youth
LGBTQIA+ individuals and their families may face disparities stemming from inequitable laws and policies, encounter societal discrimination, and lack access to quality health care(Rafferty 2018), including oral health care. ^49,50 Willingness and preparedness of oral health care professionals to treat individuals who identify as LGBTQIA+ helps promote positive oral health attitudes and inclusivity for all children.

Many LGBTQIA+ individuals face stigma and discrimination⁵¹ and experience stress and anxiety in healthcare settings.⁵² Dental fear among transgender individuals has been associated with prior experiences and fears of discrimination.⁵³ For these reason, some patients may not feel comfortable disclosing their sexual orientation or gender identity or expression.^54,55 Oral health care professionals can create a welcoming office environment for patients who identify as LGBTQIA+. Strategies to create a supportive environment and atmosphere of belonging for patients and families include the use of inclusive language such as avoiding stigmatizing words, actively listening for individual and community preferred terms and language, and utilizing person-first language.⁵⁶ Inclusive patient forms and documents create a respectful and supportive environment that helps patients feel acknowledged.⁵⁶ 

Professional education regarding oral health and oral health disparities of individuals identified as LGBTQIA+ is lacking.⁵⁰ In a 2016 survey of US and Canadian dental schools, 29% of responding schools did not offer any such content, and 12% did not know if content was covered.⁵⁵ Proper training of health care professionals to manage the unique needs of these individuals^51,57-59 and more evidence-based research regarding related health and health disparities are needed.⁶⁰

Immigrant and refugee children
One in every 4 children in the US is part of an immigrant family (ie, the child is foreign-born or resides with a foreign-born parent.)⁶¹ Immigrant and refugee children present unique needs and can encounter barriers to oral health as a vulnerable population.⁶² Children who grow up in a multicultural setting can experience differences in their oral health if there are discrepancies between parental or cultural views and the mainstream culture.⁶³ Language barriers, lack of insurance coverage, difficulties finding available oral health care professionals, reduced oral health literacy, as well as cultural views can create barriers to accessing oral health care and increase caries risk. ^9,63-66

Acceptance of health interventions as well as responses to health information can be affected by an individual’s or family’s culture.⁶⁷ Understanding and considering these factors can aid oral health care professionals when treating immigrant children and families. Oral health messages can be developed with special consideration to a community’s cultural beliefs, motivation, and knowledge. Acceptance of oral health care recommendations and treatment may be improved by training community members to participate in the delivery of care to families.⁶³ Delivering oral health information that considers a gainframed or loss-framed approach based on cultural background and acculturation can improve responsiveness.⁶⁸ Immigrant families with greater exposure to the mainstream culture may respond more positively to gain-framed messaging. An example of a gain-framed message would be if one brushes twice daily, the individual will have better oral health. ⁶⁸ Immigrant families with less exposure to the mainstream culture may respond better to loss-framed messaging. ⁶⁸ An example of a loss-framed message would be if one does not brush twice daily, the individual risks having poor gingival health and caries. Efforts to understand the cultural backgrounds of immigrant patients and families helps improve delivery of care. Oral health education delivered by culturally-appropriate oral health workers or community members can improve early childhood oral health knowledge, attitudes, and behaviors of parents and caregivers.^69,70

Children affected by armed conflicts are at risk for negative health consequences.⁷¹ The impact of war, family separation, and other forms of aggression on children’s systemic, behavioral, developmental, and psychological health can be devastating, and the physical, social, and environmental ramifications of violence and displacement are long-lasting.⁷¹ Increased access to and provision of oral health care for affected families may be achieved through both public and private pathways, such as inclusion of oral health into primary care, research inquiries that seeks to better understand the oral health needs of refugee populations, increased support for social services, expansion of insurance eligibility, development of emergency protocols to address urgent dental concerns, and prevention programs to provide oral health education in a culturally-safe manner.⁷² A trauma-informed care approach is important to help dental professionals determine optimal behavior guidance modalities for patients who may suffer from resultant psychological distress.⁷³

Indigenous children
Indigenous children in the US, specifically American Indian and Alaska Natives, have considerable oral health disparities that are amplified by poor access to care.^74,75 Dental caries occurs earlier, with a higher prevalence, and at a greater severity in Indigenous children than among the general population.^74,75 The 2014 Indian Health Service Oral Health Survey of American Indian and Alaska Natives reported 21% of 1-year-olds and 40% of 2-year-olds had early childhood caries (ECC).⁷⁶ The dependence on general anesthesia to treat patients with ECC is high among Indigenous children in North America.^74,75,77 Limited data exist on the overall number of American Indian and Alaska Native children undergoing dental surgery under general anesthesia for caries, but data from Alaska suggests that 73% of Alaska Native children had undergone general anesthesia to treat ECC.^74,75 In the more remote Indigenous regions of Canada, the rates of dental treatment under general anesthesia exceed 200 per 1000 children younger than 5 years per year, a OFFICIAL BUT UNFORMATTED rate 15 times higher than the overall annual Canadian rate.⁷⁷ Early access to preventive oral health care is essential for these Indigenous children.^74,75 Oral health promotion may be more effective if it is culturally appropriate and delivered through channels recommended by community members. ⁷⁸ Thorough discussions regarding the risks and benefits of newer treatment approaches (eg, silver diammine fluoride) with Indigenous parents can facilitate their acceptance of these treatments^.79

Military-connected children
Military-connected children face challenges and vulnerabilities caused by the unique requirements of military life. Providing care to this population requires appropriate knowledge, understanding, and appreciation of military culture.⁸⁰ The armed services represent a culturally, geographically, and ethnically diverse population with 30.4% of the force represented by racial minorities, and 19.3% of service members are females.⁸¹ In 2018, over 1.5 million dependent children were reported to be living in active duty, guard, and reserve families.⁸¹ Along with the approximately 2 million children of veterans, the total number of military-connected children in the US is nearly 4 million.⁸²

Military-connected children may experience physical separation from a parent due to participation in deployments, missions, training exercises, unaccompanied orders, and military schools. ^80,83 Deployment and its dangers can threaten a child’s sense of security and result in complex psychosocial burdens.^80,81,83-86 Studies show children have an increase in stress, emotional-behavioral challenges, and mental health visits and a decrease in academic performance during parental deployment. ^87,88 Adolescents with a deployed parent are more likely to report binge drinking, prescription drug abuse, marijuana and other substance use, peer victimization, weapon carrying, and suicidal ideations compared to teens from nonmilitary families.^84,87 Military-connected children experience an increased risk of child maltreatment during parental deployment and return/reintegration; however, overall rates of child maltreatment are generally similar to the civilian population.^83,87-89

Military-connected families may move locations every 2 to 4 years, a rate 2.4 times more frequent than their civilian counterparts. ⁸³

Frequent relocations involve changing schools, social networks, and medical and dental homes. Such transitions may interfere with continuity of care and leave some medical or dental problems unresolved. Military-dependent youth require coping strategies to adjust to relocation and deployment of family members while also confronting age-appropriate developmental stages (eg autonomy, independence).⁸⁴ Such changes can make these children and adolescents more susceptible to health-risky behaviors⁹⁰ and depression.⁹¹ Socioeconomic status may mediate care seeking behavior among military families.⁹² Some military-connected children may experience marginalization and victimization⁹¹ while others face challenges in communities where there is a lack of sensitivity to or preparation for dealing with military-connected difficulties.⁸⁵ Frequent changes in military insurance plans and perceived low reimbursements may deter some dental offices from accepting or continuing care after changes in coverage.⁹³ In one study, disparities in access to nonroutine medical care for children with SHCN were found between those from militaryconnected children versus civilian families.⁹³ Military-connected children may have an increased risk for caries⁹⁴ because consistent dental homes with preventive dental care may be lacking and fluoride exposure may be suboptimal. Sporadic dental care may be common because of frequent relocations. Inconsistent fluoride exposure may be expected if children have a history of residing in international or nonfluoridated communities. Children in single-parent or dual-military families also may be at an increased risk for caries as parents face challenges in meeting the health needs of their children. During work, training, or deployments, military-connected children may be enrolled in extensive childcare and after-school programs or cared for by extended family members where they have more frequent exposure to cariogenic foods. Familiarity with military culture and sensitivity to their oral health barriers may facilitate improved delivery and continuity of dental care as families relocate for new military assignments. 

Foster care and homeless children
Children who are homeless or in foster care present unique needs and can encounter significant barriers to oral health care as a vulnerable population. Approximately 368,500 children are in foster care in the US, and some remain in foster care until adulthood.⁹⁵ Abuse, neglect, and family disruption are the most common reasons why youth are placed in foster care.⁹⁵ Foster parents are often unable to locate dentists who accept Medicaid, and studies have found that foster children suffer from relatively poor health, unresolved or worsening health conditions, and lack of access to medical and dental care.^96,97 Foster caretakers’ own knowledge, attitudes, and experiences influence dental management and behaviors of the foster child. Foster caretakers often are challenged with the inability to consent for needed dental care and rely on social services to assist with obtaining consent from legal authorities.^96-98 Youth in foster care were reported more likely to experience caries in both the primary and permanent dentition than other children who were enrolled in Medicaid.⁹⁶

An estimated 1.5 million children experience homelessness annually in the US99 Point-in-time data from the US Department of Housing and Urban Development found that approximately 260000 people in families with children experienced homelessness on a single night in 2024, 56% of which were under the age of 18.¹⁰⁰ Risk factors for homelessness during adolescence include strained family relationships, history of abuse, mental health concerns, substance misuse, behavioral problems, history of foster care, and running away.^99.101,102 Unaccompanied youth and runaways are vulnerable to human trafficking, 103 risky sexual behaviors, teen pregnancy, and substance misuse.¹⁰² Difficulties in storing oral hygiene products, maintaining a healthy diet, and accessing safe drinking water and frequent relocation increase oral health risks for homeless families.¹⁰⁴ Homeless youth face challenges in obtaining dental care including transportation and consent for treatment and may have limited general dental knowledge.¹⁰⁵ A homeless minor may be able to provide consent for treatment based on individual state laws. The 2018 Federal Runaway and Homeless Youth Act allows for some youth to have legal rights for treatment decisions.¹⁰⁶

Policy statement

Recognizing the challenges faced by vulnerable populations in achieving optimal oral health status, the AAPD supports:

• delivery of empathetic oral health care in an environment that is sensitive to the social determinants of oral health and heightened vulnerabilities of each individual patient.
• advocacy for programs and policies that support vulnerable populations in obtaining improved access to health care services.
• pre- and postdoctoral programs as well as continuing education courses that include training oral health care professionals in cultural safety and social concerns for vulnerable populations.
• interprofessional networks that will aid vulnerable populations in accessing important health care resources.