Craniofacial and Tooth Development

Most of our knowledge about mammalian tooth development comes from animal studies. These studies, primarily in mice, show that teeth are formed through a series of interactions between the epithelium (tissues that line the outer surfaces of organs and blood vessels and the inner surfaces of cavities in many internal organs) and the mesenchyme (a type of connective tissue found during embryonic development). As the epithelium and mesenchyme interact, the developing tooth progresses through several stages, eventually leading to the differentiation of cells that secrete tissues of the crown, dentin, and enamel.

Odontoblasts, cells that are part of the dental pulp, produce dentin—the substance beneath the tooth enamel on the crown. Ameloblasts, cells present only during tooth development, produce enamel, the protective surface covering each tooth. Enamel, the hardest substance in the human body, serves as the tooth crown’s wear-resistant outer layer. Half of the ameloblasts die during enamel formation; the rest die after this process ends. Consequently, no secondary or regenerative enamel is produced (Bartlett and Simmer 2015; Lacruz et al. 2017). The tooth root starts to form after the crown takes its biological shape and is not fully formed until after the tooth has erupted into place. At this point, the tooth’s anatomic structures are complete (Figure 4). Most infants get their first teeth (incisors) within a few months after birth, usually starting around 6 months of age. Rarely, some infants are born with one or more teeth, but by 3 years of age, all 20 primary teeth should have erupted (Figure 5). Normal in utero development of the teeth, mouth, and supporting structures sets the stage for craniofacial and tooth development during early life and the beginnings of any oral diseases and conditions that may appear later.

Figure 4

Tooth anatomy.

Figure 5

Primary teeth.

Dental Caries

Of all the dental and craniofacial disorders that affect children, dental caries—the disease that causes tooth decay—remains the most prevalent. It is one of the most common chronic diseases of childhood, with about 1 in 4 preschool children having experienced caries in their primary teeth (Figure 6) and at least 1 in 6 children aged 6 to 11 years experiencing dental caries in their permanent (adult) teeth (Figure 7). Globally, it remains one of the most common chronic diseases in people of all ages (Kassebaum et al. 2017). Health care agencies, such as the World Health Organization (WHO), have identified dental caries in children as a major public health problem and have issued reports characterizing the condition and strategies to prevent it in children. More than 530 million children worldwide have untreated caries in primary (baby) teeth, with the prevalence of disease increasing with age (World Health Organization 2020). In the United States, significant disparities in the prevalence and severity of dental caries continue to persist among low-income populations and certain race/ethnic groups (Dye et al. 2017).

Figure 6

Percentage of children ages 2–5 with dental caries in primary teeth by poverty status and race/ethnicity: United States, 2011–2016. Notes: Dental caries experience (dft > 0). FPG = Federal Poverty Guideline: < 100% FPG (more...)

Figure 7

Percentage of children ages 6–11 with dental caries in permanent teeth by age group, poverty status, and race/ethnicity: United States, 2011–2016. Notes: Dented caries experience (DMFT > 0]. FPG = Federal Poverty Guideline: < (more...)

Dental caries is a multifactorial disease process that begins with an imbalance in microbial biofilms that cover tooth surfaces. Decay-causing bacteria in the mouth come into contact with sugars from food and drink, producing acids that attack the tooth’s enamel and cause mineral loss. Early in the stage of mineral loss, a noncavitated lesion arises within the enamel that can be reversed. During this early period of demineralization, the process can be reversed with exposure to calcium and other minerals from saliva, and fluoride from toothpaste or other sources. If remineralization is insufficient, over time the enamel is weakened and then destroyed, forming a cavity that, if left untreated, can cause pain, infection, and even tooth loss (Figure 8). If allowed to progress, caries can result in infection of tissues beyond the tooth itself (Divaris 2016; Pitts et al. 2017).

Figure 8

Important changes associated with dental caries progression.

Today, about 1 in 10 preschool children and 1 in 5 children aged 6 to 11 have some form of tooth decay that requires treatment (Dye et al. 2017; Centers for Disease Control and Prevention 2019). Globally, 9% of children have untreated dental caries in their primary teeth, representing the 10^th most prevalent health-related condition worldwide (Frencken et al. 2017). Dental caries can begin as soon as the first teeth erupt and is influenced by a host of biological, environmental, and behavioral factors (Seow et al. 2009; Fontana 2015).

Although genetic factors can affect susceptibility to dental caries, their interactions with environmental factors appear to be more highly predictive of dental caries in children (Shaffer et al. 2012; Silva et al. 2019). These environmental factors include increased exposure to cariogenic bacteria, high frequency of sugar consumption, inadequate salivary composition or flow, delayed or insufficient fluoride exposure, and poor oral hygiene. Other risk factors for dental caries include poverty, race and ethnicity, and maternal oral health status (Fontana 2015; Garcia et al. 2015; Fontana and Gonzalez-Cabezas 2019). Childhood dental caries and untreated caries are more prevalent and more severe among racial and ethnic minorities and in lower-income households (Dye et al. 2017; Rozier et al. 2017; Slade and Sanders 2018; Centers for Disease Control and Prevention 2019).

Research shows sociodemographic disparities in dental caries affecting permanent teeth. These disparities begin to appear soon after adult teeth emerge. More than 1 in 5 Mexican American and non-Hispanic Black children aged 6 to 11 years experience tooth decay, whereas fewer than 1 in 7 non-Hispanic White children have such decay (Figure 7). For children living in poverty, nearly 1 in 4 experience tooth decay, compared to about 1 in 8 children living in households at twice the federal poverty guideline level or higher (Figure 7). Dental caries has a higher prevalence in other minority racial and ethnic groups too. American Indian and Alaska Native (AI/AN) children aged 6 to 8 years are twice as likely to have untreated dental caries in their primary teeth, and five times more likely to have untreated caries in their permanent teeth than U.S. children overall (Phipps and Ricks 2017).

Untreated caries can lead to pain, inflammation, and spread of infection to bone and soft tissue (Figure 8). As a result, children may suffer from difficulty eating, poor nutrition, poor physical development, and poor self-image and socialization (Casamassimo et al. 2009). Academic performance also can be affected by the presence of dental caries (Ruff et al. 2019). In rare cases, lack of treatment or postoperative complications from treatment have even resulted in death (Otto 2007; 2017). In many cases, caries significantly diminishes the quality of children’s lives (Egerton 2015). Without appropriate preventive and disease-management interventions, dental caries that persists throughout the life course will have negative lifelong consequences. These conditions disproportionately affect some population groups, creating patterns of oral health inequity.

Early Childhood Caries

In children younger than 6 years, dental caries is referred to as early childhood caries (ECC), a condition defined as one or more decayed, missing, or filled surfaces attributable to caries in any primary tooth (Drury et al. 1999; Pitts et al. 2019; Tinanoff et al. 2019). Once referred to as “baby bottle tooth decay” or “nursing bottle caries,” ECC spurred epidemiologic research on dental caries in young children (Dye et al. 2015). According to the American Academy of Pediatric Dentistry (AAPD) (2020a), any sign of smooth-surface caries in a child younger than 3 years of age indicates severe ECC (S-ECC).

From 3 to 5 years of age, one or more decayed, missing, or filled smooth surfaces attributable to caries in primary maxillary anterior teeth or a decayed, missing, or filled score of at least four, five, or six surfaces (by 3, 4, and 5 years of age, respectively) also is considered to be S-ECC.

Disparities in the prevalence and severity of dental caries continue to persist in the United States, with Hispanic and non-Hispanic Black preschool children having higher average levels of dental decay than non-Hispanic White children (Dye et al. 2017; Centers for Disease Control and Prevention 2019). Poverty also remains as one of the most important indicators of early childhood dental caries experience, with about 1 in 3 preschoolers living in poverty having some form of ECC (Figure 6). The concurrence of poverty and race/ethnicity is associated with dental caries in preschool children. More Mexican American children and non-Hispanic Black children living in poverty experience caries than do poor non-Hispanic White children (Figure 9). However, for preschool children living in non-poor families, the prevalence of dental caries is the same regardless of race/ethnic status. This relationship between poverty and race/ethnicity exemplifies an important oral health inequity experienced by preschool children. Untreated dental caries affects about 10% of children aged 2 to 5 in the United States, with the highest prevalence in children living in poverty (17%) (Centers for Disease Control and Prevention 2019a). Mexican American and non-Hispanic Black children are more than twice as likely to have untreated dental caries than non-Hispanic White children (15% vs. 7%) (Centers for Disease Control and Prevention 2019a).

Figure 9

Percentage of children ages 2–5 with dental caries in primary teeth by race/ethnicity and poverty status: United States, 2011–2014. Notes: Dental caries experience (dft > 0). FPG = Federal Poverty Guideline: < 100% RG = (more...)

Of all racial and ethnic groups, AI/AN children have the highest prevalence of ECC (Ricks et al. 2015). More than half (52%) of young AI/AN children aged 1 to 5 experience ECC, and the prevalence increases to 71% for those aged 3 to 5 (Phipps et al. 2019). The prevalence of ECC increases with age. For example, one study found a prevalence of caries in AI/AN children of 7–9% at 2 years, 35–36% at 3 years, and 55–56% at 4 years (Batliner et al. 2018). An estimated 1 in 3 young AI/AN children aged 1 to 5 have untreated ECC (Phipps et al. 2019).

ECC can have negative consequences for preschool children (Tinanoff et al. 2019), including oral pain, chewing and sleeping difficulties, changes in behavior, and poorer school performance (Tinanoff and O’Sullivan 1997; Casamassimo et al. 2009). Pain not only causes suffering, but also can compromise food intake, leading to weight loss and delayed growth and development (Sheiham 2006; Phantumvanit et al. 2018).

Among the contributors to the prevalence of ECC, a key factor is free sugar—all the monosaccharides and disaccharides that food manufacturers, cooks, and consumers add to foods—plus sugars naturally present in a variety of foods and beverages, such as honey, syrups, fruit juices, and milk (Moynihan and Kelly 2014; Sheiham and James 2015). The dental caries chain of causality can be broken by eliminating the use of free sugars, such as those offered in the form of sugary drinks between meals or at night (Chaffee et al. 2015). Delaying the introduction of free sugar into a child’s diet and promoting healthful eating practices could contribute significantly to future health status and could prevent, or at least delay, the onset of dental caries (Feldens et al. 2010; Vitolo et al. 2010).

The first clinical sign of ECC is noncavitated lesions, which appear as white or brown spots on teeth. Early recognition of these lesions can lead to using interventions such as fluoride, fluoride varnish, or fluoride-releasing glass ionomers, depending upon the tooth surface area affected to encourage remineralization and arrest further lesion development. However, if risk factors, such as poor oral hygiene or frequent exposure to free sugars persist, these lesions can progress to cavities and ultimately to tooth destruction (Figure 10).

Figure 10

Early childhood carles (ECC) In preschool children.

Without an early diagnosis, ECC treatment often requires restorative procedures or tooth extraction, both of which can be technically, financially, and emotionally complex in young children. Depending on the child’s age, as well as the number and extent of the cavities, safe and effective treatment may require hospitalization and general anesthesia, which involve additional costs and risks (Casamassimo et al. 2009; Tinanoff and Reisine 2009). Cost estimates to treat dental caries for young children under general anesthesia in a hospital can vary widely, but the United States Indian Health Service estimates these costs to be as much as $9,350 per child (Atkins et al. 2016; Phipps et al. 2019). ECC treatment involves formidable complexity and cost. Along with incorrect perceptions that primary teeth don’t need to be treated because they eventually will be replaced, this could explain why in many parts of the world almost no children with ECC are treated (Phantumvanit et al. 2018).

Craniofacial Anomalies

Craniofacial anomalies result from variations in the growth pattern of the head and the face. These congenital conditions have multiple causes, including genetics and environmental exposures (WHO Registry Meeting on Craniofacial Anomalies et al. 2003; Parker et al. 2010), as well as a combination of these two factors. Most craniofacial anomalies are serious lifelong disabilities that require extensive treatment and have an impact on oral function, appearance, and quality of life across the lifespan (Sischo et al. 2017).

Serious birth defects are estimated to occur in 6% of births worldwide, or about 7.9 million infants (Christianson et al. 2006). Most of these birth defects are associated with a wide variety of craniofacial anomalies, including orofacial clefts, skull deformities, malformation and malalignment of the jaws, missing and malformed teeth, and premature tooth loss arising as a result of complications from the anomalies. Craniofacial birth defects, and in particular, cleft lip and/or palate, occur as often as 1 in 700 live births and represent the most common congenital disorder, after Down syndrome (Mai et al. 2019). Craniofacial disorders also can directly influence risk for and resistance to common oral diseases such as dental caries and periodontal disease (Gaggl et al. 1999; Mucci et al. 2005; Huynh-Ba et al. 2009; Antonarakis et al. 2013; Vieira et al. 2014).

Cleft lip, cleft palate, or both (CL/CP), a separation of the lip, palate, or both, are the most common of all craniofacial anomalies in children. These anomalies include alterations in tooth size, shape, and number, as well as malocclusions and nasal deformities. Clefts are the second most common birth defect in children (Parker et al. 2010), after Down syndrome. The Centers for Disease Control and Prevention (CDC) estimates that each year in the United States, about 2,650 babies are born with a CP (1 in 1,574 newborns) and 4,440 babies are born with a CL, with or without a CP (1 in 1,000 newborns). These birth defects occur more often in Asians and AI/ANs and less often in African Americans. CP seems to be slightly more common in females, whereas CL, with or without CP, is more common in males (Michalski et al. 2015).

The separation seen in CL/CP occurs when the medial nasal process and the maxillary process fail to fuse early in fetal development. Although 70% of both cleft types result from unknown causes, other cases involve known risk factors, including genetics, exposure to toxic or environmental substances, and nutritional deficiencies during fetal development. Among persons with both CL and CP, about 30% have an associated genetic defect (see Figure 9 – Section 6 in this monograph for more detailed information on genetic syndromes). Genes associated with clefting include IRF6, MSX1, FGF, and BMP4 (Twigg and Wilkie 2015). Other factors known to increase the risk for CL/CP malformations include maternal smoking, insufficient folic acid, family cleft history, child’s gender, maternal education, and maternal race and ethnicity (Raut et al. 2019).

Besides CL and CP, other, rare craniofacial anomalies can impact a child’s quality of life. Osteogenesis imperfecta had an incidence of 4.54 per 100,000 live births in Texas from 1999 to 2006; less severe cases may be identified later in childhood (Moffitt et al. 2011). The recessive dystrophic type of epidermolysis bullosa, which has oral manifestations, had an incidence of 3.05 per 1 million live births in 1986–2002 (Fine 2016). The incidence of craniosynostosis from 1989 to 2003 in metropolitan Atlanta was estimated at 4.3 per 10,000 live births (Boulet et al. 2008), with the anomaly occurring twice as often in males as in females (Michalski et al. 2015).

Other craniofacial anomalies in children that can strongly influence a child’s oral health and overall well-being include:

• Pierre Robin sequence (PRS), defined by an undersized lower jaw (micrognathia), posterior CP, and downward displacement of the tongue (glossoptosis), affects 1 in 8,500–14,000 persons (Mackay 2011). It can cause life-threatening eating and breathing difficulties in infants. Genetic mutations near the SOX9 gene are the most common cause of nonsyndromic PRS. Environmental conditions in utero, such as abnormal pressures on developing tissues, also can contribute to the characteristic small jaw (Benko et al. 2009; Amarillo et al. 2013; Tan and Farlie 2013).
• Treacher Collins syndrome (TCS), or mandibulofacial dysostosis, is associated with underdeveloped facial bones, particularly the cheekbones, with a small lower jaw. The maxilla and zygoma can be affected as well. Key characteristics include abnormalities of the external- and middle-ear ossicles, downward-slanting openings between the eyelids (palpebral fissures) with notching of the lower eyelid, and CP. A mutation in the TCOF1 gene encoding treacle 4–7 is associated with TCS. This particular gene mutation (TCOF1) is only one of multiple known gene mutations that can cause TCS. Neural crest-cell formation and proliferation also appear to play a role (Jones et al. 2008).
• A genetic defect on chromosome 22 causes 22q11.2 deletion syndrome, also known as DiGeorge or velocardiofacial syndrome. The clinical manifestations vary but include congenital heart defects, palatal defects, and leakage of air into the nasal passages during speech (velopharyngeal dysfunction), which can contribute to feeding difficulties (Robin and Shprintzen 2005; Bassett et al. 2011).
• Lack of development in the size and shape of facial structures on one side of the face characterizes craniofacial microsomia, also known as hemifacial microsomia. Affected children typically are described as having maxillary and mandibular jaw underdevelopment, contributing to difficulties with feeding, speech, and breathing. Children also may have ear abnormalities or an absent external ear, which leads to hearing loss (Gougoutas et al. 2007; Werler et al. 2009).
• Craniosynostosis, the premature fusion of the sutures (joints of the skull), causes increased intracranial pressure and leads to restricted brain and skull growth. Treatment often involves surgery early in infancy to relieve the pressure and allow the brain to grow. Future studies are needed to understand suture stem cell behavior, the mechanisms behind premature suture closure, and possible therapeutic interventions.

Children born with craniofacial anomalies may have significant psychosocial, as well as physical, issues and consequently may experience some reduction in quality of life. A variety of instruments are used to determine how a child’s oral conditions affect them in terms of physical symptoms, emotional well-being, peer interactions, school experience, and functional well-being (Tapia et al. 2016). Among the few reports on children with craniofacial anomalies, one found that high-functioning patients with TCS had quality-of-life scores comparable to those of children without such anomalies (de Oliveira et al. 2018). More often, though, studies indicate that craniofacial anomalies significantly affect a child’s social development. By 9 years of age, children with CL/CP have greater anxiety and behavioral inhibition. Self-ratings of popularity are below average, and girls with clefts of the lip and palate experience a decrease in self-worth during adolescence (Leonard et al. 1991). These children may need support for developing resilience, social skills, and emotional resources to prevent social isolation and low self-esteem (Lewis et al. 2017).

Developmental Tooth Defects

Developmental tooth defects are irregularities in tooth formation that occur at 6 weeks of fetal development for primary dentition and continue through formation of the third permanent molars in late adolescence (Wright 2000). Several types of defects involve tooth development, but the main three are dental fluorosis, enamel hypoplasia, and amelogenesis imperfecta. All three result from factors affecting tooth enamel mineralization. Amelogenesis imperfecta is a genetic disorder that affects the developing structure and appearance of tooth enamel, whereas enamel hypoplasia is caused by either hereditary or environmental factors that lead to inadequately formed tooth enamel. Amelogenesis imperfecta affects 1 in 14,000 persons (Crawford et al. 2007). Other types of developmental tooth disorders include congenitally missing teeth (hypodontia), which is rare in primary teeth, although the prevalence of hypodontia in permanent teeth in North America is 3.7% (Polder et al. 2004). Extra (supernumerary) teeth may be found in up to 2.0% of the population (Russell and Folwarczna 2003).

Dental fluorosis is a form of hypomineralization of enamel that can occur as a result of ingestion of too much fluoride during enamel formation. Dental fluorosis can range from barely visible white spots or lines in teeth in milder cases to converged opaque areas and pitting in severe forms. Dental fluorosis is common in the United States, affecting at least 33% of children aged 6 to 11 and 41% of youth aged 12 to 15 (Beltrán-Aguilar et al. 2010), with most of these being the mild or less severe forms, which are typically considered not an aesthetic issue by many.

Genetic, environmental, and nutritional factors, as well as injury, illness, and birth weight can influence developmental tooth defects (Wright 2000; Thesleff 2006). The most common developmental abnormalities of the teeth relate to changes in the number of teeth, such as missing teeth; supernumerary, fused, and geminated (double) teeth; changes in the size and shape of teeth, such as peg or small lateral teeth; and changes in position because of ectopic or out-of-place tooth eruption (American Academy of Pediatric Dentistry 2021). In addition, developmental defects of enamel can affect dental caries susceptibility (Vargas-Ferreira et al. 2015; Costa et al. 2017; Foulds 2017). Dental and medical teams working together to provide ongoing health care maintenance, anticipatory guidance, and acute care are more likely to ensure timely diagnosis and referral. In this way, members of interprofessional health care teams can function as advocates for children, providing necessary liaisons for needed services (Lewis et al. 2017).

Orofacial Pain

Pain is an unpleasant sensory and emotional experience usually associated with actual or potential tissue damage. Reactions to pain are highly individualized (International Association for the Study of Pain 1994). Dental pain in children most often stems from dental caries. Untreated dental caries can result in urgent and costly visits to the dentist or hospital emergency department. It disproportionately affects individuals with inadequate access to care, especially children who are members of racial and ethnic minority groups or living in poverty.

Dental pain is not an uncommon event, yet an accurate assessment of the prevalence of dental pain among children is largely unknown. In a survey of Maryland elementary school-age children, nearly 12% of all children surveyed reported experiencing some lifetime dental pain, and this increased to 28% among those who had dental caries (Vargas et al. 2005). A review conducted 2 decades ago estimated lifetime prevalence of oral pain among youth ranging from 5% to 33% globally (Slade 2001). Both of these studies reported that children of lower socioeconomic status were more likely to experience dental pain in their lifetimes, suggesting that dental pain in childhood is a health disparity accentuated by poverty.

In the pediatric population, it is important to examine two aspects of dental pain: pain resulting from oral diseases and problems associated with pain management such as sedation, hospital admission, or general anesthesia. The first aspect acknowledges dental pain as one of five vital signs and further recognizes its effects on daily life including learning, growth and development, socializing, and use of dental services (Casamassimo et al. 2009). The second aspect has an influence on care system utilization and an impact on the costs associated with pain management and treatment of underlying dental disease. For example, dental pain shifts the care pattern from primary preventive care to emergency care, often in hospital emergency departments.

A report examining emergency room visits for dental complaints in children and adolescents noted that for 1,081 such visits during a 5-year period, the most common complaint was pain (51% of patients) (Friedman et al. 2018). A study examining 769 children 5 years of age, noted that difficulty eating and speaking because of oral problems was associated with a history of dental pain (Gomes et al. 2020). Yet another study examining self-reported dental pain in 8- to 10-year-old children in Brazil noted that 51.5% of 819 children reported episodes of dental pain in the month before the study. In addition, the presence of dental pain was significantly associated with trouble sleeping, difficulty eating, school absenteeism, difficulty paying attention in class and doing homework, and avoidance of recreational activities (Santos et al. 2019). Examining U.S. populations, one study noted that among children receiving treatment at a tertiary care children’s hospital, the mean duration of pain was 17.7 days (Thikkurissy et al. 2012). In addition, 26% of these children described their pain as severe. Finally, it has been reported that one-third of all dental treatments result in pain or discomfort. For example, dental extractions were painful in 62.4% of cases, with injection of local anesthesia reported as the major source of pain. Operative treatments were painful in 38.8% of procedures, with preparing the tooth with dental drills cited as the most common reason for pain and discomfort (Ghanei et al. 2018).

Dental Erosion

Dental erosion is the irreversible, acid-induced loss of dental hard tissues, not involving the bacterial-secreted acids associated with dental caries (Ganss 2014). It may be caused by extrinsic acids, such as acids from juice, soda, fresh fruit, and sour candies; hypochlorous acid from chlorine used in swimming pools (Lussi 2006; Lussi and Jaeggi 2006; Taji and Seow 2010); and intrinsic, gastric acid as a result of reflux (Lussi 2006; Lussi and Jaeggi 2006).

A systematic review on dental erosion in children and adolescents’ permanent teeth estimated a global prevalence of 30.4% (Salas et al. 2015), which is lower than a separate estimate of 39.8% among U.S. children (Okunseri et al. 2011). Dental erosion in children most often affects occlusal (chewing) surfaces of first primary molars, followed by occlusal surfaces of second primary molars and then mesial-cusp tips of permanent first molars. The first sign of erosion on first primary molars is on cusp tips; the erosion then progresses to encompass the entire occlusal surface. The lingual (next-to-the-tongue) surfaces of maxillary incisors may display erosion if a child has a tongue-thrust swallow (when the tongue presses too far forward in the mouth), which propels acidic liquid forward during swallowing.

Gastroesophageal reflux disease (GERD) is suspected if severe erosion is associated with loss of primary molar occlusal-surface anatomy (Pace et al. 2008; Ranjitkar et al. 2012). Identifying GERD is important because the risk of developing esophageal adenocarcinoma later in life is estimated to be 43 times greater in individuals with untreated GERD than in those without GERD (Lagergren et al. 1999).

Dental Trauma

Dental traumatic injuries can be classified as avulsion, or complete loss of the tooth; luxation, or displacement within the bone but still in the mouth; or fracture, in which the tooth is broken. In preschool children, teeth are most commonly luxated (displaced) or avulsed (knocked out) as a result of reduced bone density (Andersson 2013). Accidental, or unintentional trauma, is the greatest source of dental trauma. In preschool-age children, dental trauma is one of the more common injuries, accounting for almost 20% of all bodily injuries among young children (Malmgren et al. 2012). The highest incidence of trauma affects primary maxillary incisors in children 2 to 3 years of age, when motor skills are developing (Flores 2002; Avşar and Topaloglu 2009). More information on dental trauma is located in Section 2B.

Caregiver Oral Health Behaviors

Parental oral health behaviors affect children’s oral health (Case and Paxson 2002; Isong et al. 2010). Parents who have poor oral hygiene, who do not get dental care, and whose diets promote tooth decay are more likely to have caries, untreated decay, and high levels of oral cariogenic bacteria. These behaviors also affect their children (Chaffee et al. 2014). Children of mothers with high levels of untreated tooth decay are more than three times as likely to have treated or untreated dental caries as children of mothers who have no untreated decay. Similarly, children of mothers with greater tooth loss are more than three times as likely to have higher levels of caries experience as children of mothers with no tooth loss (Dye et al. 2011).

Rural parents are less likely to utilize preventive health care visits or preventive dental care visits for their children than urban parents (Probst et al. 2018). Like other rural children, AI children living on reservations have less access to these prevention measures and also experience unusually high levels of dental caries (Batliner et al. 2013; Wilson et al. 2014; Batliner et al. 2018). Moreover, fluoridated water supplies often are not available in rural areas. For some parents, fear of environmental, chemical, and pesticide contamination, including in well-water sources, increases the consumption of bottled water, which reduces the preventive effects of community water fluoridation even when it is available (Scherzer et al. 2010; VanDerslice 2011).

Dietary Behaviors

Diet during the formative years affects children’s immediate risk for caries and their development of taste and food preferences that influence the risk for caries throughout their lives (Hooley et al. 2012). An association between tooth decay and obesity has been shown in children living in high-income countries, but not in those living in low- and middle-income countries (Hayden et al. 2013; Chen et al. 2018). This relationship is likely attributable to shared societal and environmental risk factors, including poor-quality diets and other socioeconomic factors. For example, children of low socioeconomic status are at increased risk for food insecurity, which is associated with lower vegetable intake and higher sugar intake (Eicher-Miller and Zhao 2018).

Oral bacteria ferment carbohydrates, including sugars and ultra-processed starches, to produce acids, which demineralize enamel and dentin during the caries process. Soda, fruit juice, and some infant formulas contain added sugars that can lead to caries. These added sugars are concentrated in ultra-processed foods with limited nutritional value. Many children, irrespective of age, race, ethnicity, or family income, consume too much sugar. About 60% of children aged 2 to 5 years and 58% of older children consume more added sugars than recommended by U.S. Dietary Guidelines for Americans (U.S. Department of Health and Human Services and U.S. Department of Agriculture 2015). The American Heart Association recommends that sugar in foods and drink should be avoided in children under 2 years (Vos et al. 2017). In addition, the American Academy of Pediatrics (AAP) recommends that 100% fruit juice should not be introduced before 12 months of age, and should be limited to no more than 4 ounces a day for children aged 1 to 3 years (Heyman and Abrams 2017). Although milk consumption by children has historically received wide support from professional organizations, AAP and others now are recommending that flavored milk be avoided in preschool children as a strategy to reduce added sugar intake (Muth 2019; Lott et al. 2019).

The top two sources of added sugars for children aged 2 to 18 years are sugar-sweetened beverages (SSBs) and baked goods with added sugars. Children aged 2 to 8 years and 9 to 19 years in the top decile of added-sugar consumption consume more than 50% and 64%, respectively, of their added sugars from these two categories (Bailey et al. 2018). Among children and adolescents aged 2 to 18, 11.5% of boys and 9.5% of girls consume three or more SSBs per day. Whereas energy intakes from SSBs do not differ by race among boys, non-Hispanic Black girls consumed more energy from SSBs than Hispanic girls, according to the 2011–2014 National Health and Nutrition Examination Survey (Rosinger et al. 2017).

Behaviors that increase either frequency or length of exposure to sugars and ultra-processed starches increase caries risk (Marshall et al. 2003; Palmer et al. 2010). Skipped meals, prolonged snacking or sipping, and freely available food outside of mealtimes or adult supervision are associated with increased caries risk (Dye et al. 2004; Bruno-Ambrosius et al. 2005). Nighttime bottle feeding; prolonged use of a sippy or no-spill cup with sugary beverages, including fruit juices; and frequent between-meal consumption of sugar-added snacks or drinks also increase caries risk, because these behaviors prolong tooth exposure to sugars (Tinanoff and Palmer 2000). In particular, nighttime exposure of teeth to SSBs is an important risk factor for ECC because salivary flow, which protects against caries, decreases during sleep. A study of more than 2,500 California children from diverse backgrounds showed that those with a history of falling asleep while sipping SSBs at 1 year of age had a risk of ECC that was four times higher (95% confidence interval = 1.9, 8.5) than children who had not gone to sleep with SSBs. It has been recommended that fluoride toothpaste should always be the last thing to touch a child’s teeth before sleep (Silva et al. 2016).

Management of Craniofacial Disorders

Management and treatment of craniofacial disorders have improved the lives of thousands of children and their families. Contemporary approaches to care address function (speech therapy and nutrition), psychosocial aspects (psychology and social work), and developmental and related issues (orthodontics and otolaryngology). Surgical treatment for children with craniofacial anomalies typically involves an interdisciplinary team of specialists, including oral and medical surgical specialists, pediatric dentists, orthodontists, and prosthodontists to achieve an optimal aesthetic and functional result. Some surgical procedures are carried out in infancy; others are best done after growth is complete. Temporary anchorage devices (screws and miniplates) now aid orthodontists and reduce surgical interventions. Surgery performed on the jaws and procedures on soft tissues often are important for facial aesthetics and speech.

Most children with craniofacial disorders are identified early, cared for by a primary care physician and a range of specialists, and receive care at a health center that provides treatment specific to their disorder. Such children often have oral issues that may involve a range of dental professionals, with primary care by a pediatric dentist, craniofacial orthopedics by an orthodontist, bone grafting and orthognathic care by an oral and maxillofacial surgeon, and transitional restoration and prosthetics from a prosthodontist. Fortunately, effective measures to correct craniofacial disorders are advancing and can reduce disability and improve overall health through adulthood. Craniofacial disorders have complex and often unknown or multifactorial causes. Genetic research and advances in genome science may lead to preventive strategies.

Management of Dental Caries

Contemporary management of dental caries in children typically begins with a caries management plan that includes a strong focus on prevention, assessment of a child’s risk, surveillance to evaluate disease progression, and preventive and nonrestorative treatment for carious lesions, along with restorative treatment when indicated (Slayton 2015). An accurate assessment of caries risk is an important first step in managing tooth decay and monitoring oral health improvement over time. A CRA helps in formulating an individualized treatment plan that identifies factors (biological, environmental, and social) that contribute to the development and progression of dental caries. Contemporary CRA approaches usually incorporate several if not all concepts originating from Caries Management by Risk Assessment protocols, which were developed in the late 1990s (California Dental Association 2019). Some young children and children with special health care needs (SHCN) require more active prevention and management of caries. These strategies may include comprehensive restorative care, which can require the use of sedation and general anesthesia, which carry possible health risks (Sinner et al. 2014). This approach is expensive (Berkowitz et al. 2011) and may not prevent the recurrence of caries (American Academy of Pediatric Dentistry 2020b). Alternatively, more active prevention and management may include a chronic disease management (CDM) approach (Ramos-Gomez et al. 2010; Edelstein and Ng 2015), interim therapeutic restorations (American Academy of Pediatric Dentistry 2020c), and active surveillance (American Academy of Pediatric Dentistry 2020d). CDM is a patient- and family-centered, risk-based approach to achieve individualized behavioral and treatment goals. Care providers use techniques such as self-management goals and encouraging parent engagement through coaching, role modeling, positive reinforcement, and motivational interviewing (MI) (Edelstein and Ng 2015) to try to reduce dental caries risk (Featherstone 2006). Providers may need to recall high-risk patients on a more frequent basis to monitor their caries disease.

A major component of dental caries management involves limiting the consumption of foods and drinks with free sugars, which are aggressively marketed to children and adolescents. The WHO (2015) suggests limiting intake of free sugars to 5% of total calories to minimize the risk of dental caries and other oral health conditions (FDI World Dental Federation 2016). Steps can be taken to regulate the amount of sugar in food and drink and to educate families on how to limit dietary sugar. These steps can include efforts to promote healthy eating, such as avoiding added sugar before 2 years of age and restricting sugar intake during childhood and adolescence, as well as broader social and policy changes, such as reducing sugar availability at school, establishing labeling rules that make products less attractive to children, and reducing the affordability of sugary drinks. It is important that these steps be taken early in children’s lives because they benefit not only oral health, but overall health, as well.

The importance of establishing good oral health behaviors early in childhood underlies recommendations by the American Dental Association (ADA), AAPD, and AAP that children establish an ongoing relationship with a dentist (that is, a dental home) between 6 and 12 months of age to ensure that the first dental visit occurs during a child’s first year of life (American Academy of Pediatric Dentistry 2020e). This initial visit includes an early assessment and appropriate preventive strategies to help promote the eruption of healthy primary teeth and overall oral health. It also should include advice to brush the child’s teeth twice daily with the correct amount of fluoride toothpaste, reduce the consumption of sugar, and prevent injuries (American Academy of Pediatric Dentistry 2020f). Professionally applied fluoride varnish should be considered for all infants and children younger than 5 years of age (U.S. Preventive Services Task Force Draft Recommendations 2021).

Fluorides for Dental Caries Prevention and Management

Systemic exposure to fluoride occurs as the result of dietary intake of natural substances, including water and food, through inadvertent ingestion of fluoride from dental products such as fluoride toothpaste, and other sources in which fluoride is purposefully added at the community levels as a public health benefit. The use of fluoride-containing products is one of the most important strategies for the prevention of dental caries. Evidence-based fluoride strategies, which can prevent the development of lesions, also have the potential to arrest and remineralize noncavitated dental caries lesions (Slayton 2015). Present in saliva and plaque, fluoride works to prevent early caries by inhibiting the demineralization of sound enamel and enhancing the remineralization (recovery) of demineralized enamel (Featherstone 1999). Fluoride also inhibits dental caries by affecting the metabolic activity of cariogenic bacteria (Buzalaf et al. 2011). There are many safe and effective ways to use fluoride, from community water fluoridation to toothpaste, mouth rinses, and professionally applied products such as gels and varnishes (Marinho et al. 2013; Wright et al. 2014).

Fluoride and the mechanisms that promote dental fluorosis were widely studied in the 1930s and 1940s by H. Trendly Dean and others (Centers for Disease Control and Prevention 1999a). As a result of that landmark research, an epidemiologic relationship between fluoride concentration in water supplies, dental fluorosis, and dental caries began to materialize from information collected across 21 cities in four states (Centers for Disease Control and Prevention 2021). This understanding ultimately formed the justification for supporting an original fluoride concentration of 1 milligram per liter (mg/L) in water supplies to reduce dental caries incidence, while maintaining a very low risk for the more severe forms of dental fluorosis. Community water fluoridation, a cost-effective community-based mode of prevention, benefits everyone, including children in low-income families (O’Connell et al. 2016; Slade and Sanders 2018; Sanders et al. 2019). Given the benefits most Americans have experienced with reduced severity of tooth decay as a result of water fluoridation, CDC (1999b) named community water fluoridation 1 of 10 great public health achievements of the 20^th century. For these reasons, Healthy People 2030 has as an objective to increase the percentage of the U.S. population served by community water systems with optimally fluoridated water to 77.1% (U.S. Department of Health and Human Services 2020). As of 2018, 73% of the U.S. population on community water systems received optimally fluoridated water compared to 65% of the population in 2000 (Centers for Disease Control and Prevention 2020b).

Although the efficacy of water fluoridation to prevent caries is well known, the number of people with access to this preventive measure remains low in some areas of the country. In fact, some communities have discontinued optimal water fluoridation. While budgetary concerns may contribute to these decisions, community water fluoridation has been discontinued in some locations as the result of organized opposition based on false and unscientific arguments. Unfortunately, communities not fluoridating their water supplies will usually have higher rates of dental caries (McLaren et al. 2016; Meyer et al. 2018). The original recommendation for the optimum level of fluoride in drinking water ranged from 0.7 mg/L to 1.2 mg/L (U.S. Department of Health, Education, and Welfare 1962), depending on children’s estimated water intake and the area’s mean maximum air temperature. Because Americans now have access to more sources of fluoride than they did when water fluoridation was first introduced, and national surveillance data was indicating higher levels of dental fluorosis, among other reasons, the U.S. Department of Health and Human Services updated its recommendation for the fluoride concentration in drinking water to 0.7 mg/L in 2015 (U.S. Department of Health and Human Services Federal Panel on Community Water Fluoridation 2015). Efforts are underway to align the level of fluoride added to bottled water with this recommendation (U.S. Food and Drug Administration 2019).

In addition to the systemic caries-preventive effects of community water fluoridation, fluorides also are applied topically to increase the concentration of fluoride ion at the enamel surface. Fluoride varnish has a high concentration of fluoride ion—typically 2.6%—in a natural or synthetic resin base and is applied to the surface of primary and permanent teeth to help prevent caries lesions or arrest noncavitated caries lesions (Slayton et al. 2018). It was developed in the 1960s and gradually became widely used as an anticaries agent in Europe and Canada by the 1990s for children and adults (Seppä 2004). The U.S. Food and Drug Administration cleared fluoride varnishes in 1994 for use as cavity liners and as desensitizers for hypersensitive teeth. However, fluoride varnish is primarily used today as a caries-prevention agent, an “off-label” use ADA has endorsed (Weyant et al. 2013), and varnish recently has been used to treat noncavitated lesions (Slayton et al. 2018). Given the risk of nausea and vomiting associated with unintentional swallowing, only medical and dental providers should apply fluoride varnish to children younger than 6 years (Weyant et al. 2013; Garcia et al. 2017). Because application is recommended beginning at 1 year of age, some concern about an effect on developing teeth or on other possible adverse events has been raised but is not supported by evidence (Garcia et al. 2017).

The 2000 Surgeon General’s report on oral health confirmed that fluoride varnish effectively prevented carious lesions, but questions remained concerning the optimal number and interval of applications of varnish (U.S. Department of Health and Human Services 2000a). In 2006, the ADA Council on Scientific Affairs released clinical recommendations focused strictly on prevention of caries in primary and permanent teeth, depending on a patient’s caries-risk status. It concluded that children with a low risk for caries may not benefit from fluoride varnish applications, although the Council recommended that children younger than 18 years and at moderate risk receive varnish applications every 6 months. For high-risk children younger than 18 years, varnish applications were recommended at 3- or 6-month intervals (American Dental Association 2006). A 2013 ADA systematic review of these recommendations streamlined moderate and severe caries risk into one category of elevated risk. The previous application schedule was revised slightly to recommend applications at least every 3–6 months. Other than supervised brushing with an over-the-counter fluoride-containing dentifrice, fluoride varnish is the only topical fluoride recommended for children younger than 6 years (Weyant et al. 2013). In 2014, the U.S. Preventive Services Task Force recommended a schedule for fluoride varnish application specifically by non-dental personnel (U.S. Preventive Services Task Force 2014 (May)), supporting the unique opportunity to provide this preventive strategy to children in medical settings, especially in the early years of life when they are more likely to regularly see a medical provider than a dental provider.

Clear evidence supports fluoride toothpaste’s effectiveness in preventing and controlling dental caries (Walsh et al. 2019). An age-appropriate amount of toothpaste—a small “smear” (approximately 0.1 mg fluoride or the size of a grain of rice) for children under 3 years and a “pea-sized” amount (approximately 0.25 mg fluoride) for children aged 3 to 6 years—has been recommended to minimize the risk of fluorosis because of inadvertent toothpaste swallowing (Wright et al. 2014). A recent systematic review found that toothbrushing without fluoride toothpaste only reduces plaque accumulation; it offers no protection from dental caries (Hujoel et al. 2018). Brushing twice a day with fluoride toothpaste has been suggested as a reasonable goal for imparting caries prevention. To control the amount of toothpaste used and the risk for fluorosis, parents or caregivers should help brush the teeth of preschool children 2 years of age and older twice a day, beginning with eruption of the first tooth, with a fluoride toothpaste containing between 850 to 1150 parts per million of fluoride (U.S. Food and Drug Administration 2020).

In terms of overall safety, several systematic reviews have found that fluoride is safe for use in various forms and is indicated for both self-care (Marinho et al. 2003; Wright et al. 2014) and professional use (Beltrán-Aguilar et al. 2000; Crystal et al. 2017). No acute adverse effects were found in a large study investigating fluoride varnish’s short-term safety (Garcia et al. 2017). Some reviews also support the home use of prescription-strength fluoride mouth rinse (0.09%) and fluoride gel or paste (0.5%) for children aged 6 and older, plus professionally applied fluoride varnish (2.26%) and fluoride gel (1.23% acidulated phosphate fluoride) at least every 3 to 6 months for all children at risk for developing caries (Weyant et al. 2013). Only 2.26% fluoride varnish is recommended for children younger than 6 years, applied by medical or oral health professionals beginning with eruption of the first tooth (Weyant et al. 2013; Garcia et al. 2017). Another product, containing 38% SDF (discussed in more detail in Chapter 4) recently has become commercially available in the United States for the arresting of cavitated carious lesions.

Dental Sealants for Caries Prevention and Management

Dental sealants, thin plastic coatings that protect the tooth, are placed on the occlusal (chewing) surfaces of posterior teeth to prevent caries initiation and to stop the progression of noncavitated lesions to a point where damage to dental enamel is irreversible. Sealants provide a physical barrier that inhibits microorganisms and food particles from collecting in pits and fissures (Wright et al. 2016; Slayton et al. 2018). In addition to being provided directly in dental practices, they also can be provided through school-based community programs or by dental hygienists embedded in medical practices. Sealant programs in elementary and middle schools, which serve children who otherwise would not receive preventive dental care, have been highly cost-effective. Each tooth sealed saves more than $11 in dental treatment costs (Griffin et al. 2016). According to the CDC (2016), applying sealants in schools to the teeth of the nearly 7 million low-income children who do not already have them would prevent more than 3 million cavities and save up to $300 million in dental treatment among these children.

The effectiveness of dental sealants, particularly resin-composite materials, depends on long-term retention. Nevertheless, sealants typically protect against 80% of cavities for 2 years and continue to protect against 50% of cavities for up to 4 years (Community Preventive Services Task Force 2013). About 2 in 5 children aged 6 to 11 years have at least one dental sealant applied to a permanent tooth, but children living in lower-income families are less likely to have access to dental sealants (Centers for Disease Control and Prevention 2016). Although the use of sealants in children continues to increase, dental sealants are generally underused and differences between low- and high-income groups persist (Centers for Disease Control and Prevention 2019a). Parents’ lack of awareness of the benefits of dental sealants continues to influence this underutilization. Only 55% of parents of children younger than 18 years have knowledge of dental sealants, and the level of awareness is even lower among low-income and racial- and ethnic-minority parents (Junger et al. 2019).

Prevention and Management of Dental Trauma

Prevention and management of trauma to the primary dentition of younger children is highly dependent on their activities and the supervision of parents, who may benefit from anticipatory guidance from dental professionals. Active involvement in contact sports puts children at greater risk for dental injury, and protective gear for sports, including mouth guards to reduce the likelihood of injury, should be used (American Academy of Pediatric Dentistry 2020g). Reinsertion of avulsed primary teeth is not recommended because of the difficulty in treatment, poor prognosis, and eventuality of a succedaneous tooth in its place. Additional discussion of prevention of injury in adolescents can be found in Section 2B.

Dental Educational Settings

Comprehensive, low-cost dental care for children is provided in a wide variety of settings, including 300 dental hygiene training programs (American Dental Hygienists’ Association 2021), 76 North American dental schools, 82 pediatric dentistry residency programs in universities and hospitals, and many of the 259 hospital-based general practice residencies and university-based advanced education in general dentistry programs (Commission on Dental Accreditation 2021). Because these programs’ primary mission is provider education, rather than patient services, these sites typically provide lower volumes of care than other components of the safety net. Pediatric dentistry training programs may constitute a particularly valuable part of the dental safety net for young children, as demonstrated by one program in which one-third of children younger than 6 years of age were treated for emergency relief of nontraumatic pain or infection, often on referral from other dental providers (Meyer et al. 2017).

Early Childhood Oral Health Programs

Oral health programs and policies for children typically come from the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration (HRSA), and CDC. These public agencies develop policy and funding mechanisms that affect pediatric oral health and, in turn, state Medicaid and CHIP programs, Head Start, and state and local health departments (Mandal et al. 2014; Orynich et al. 2015; Edelstein 2018).

Professional organizations, such as AAPD, AAP, and ADA have a long history of supporting and improving oral health policies for children. These organizations bring together stakeholders from diverse backgrounds to develop smarter strategies for America’s children to achieve optimal oral health. They produce policy and technical briefs related to issues such as the workforce, oral health in primary care, Medicaid and CHIP reform, and water fluoridation. They also monitor federal and state health insurance exchanges and offer guidance on cost-effective ways for states to strengthen their programs. Other advocacy organizations of this type include AAPD’s Pediatric Oral Health Research and Policy Center, the Children’s Dental Health Project (as of January 2020, its activities have moved to Community Catalyst), and ADA’s Health Policy Institute. In addition, the HRSA-funded National Maternal and Child Oral Health Resource Center, a resource library, serves the maternal and child health community with high-quality oral health technical assistance, training, and resources.

School-Based Oral Health Programs and School-Based Health Centers

Using schools to provide oral health care has a long and successful history for some communities. Some U.S. schools have dental operatories or portable dental operatory equipment set up in multipurpose rooms, or mobile dental clinics that travel from school to school. For example, Cincinnati, Ohio, city schools have a brick-and-mortar dental clinic serving children enrolled at that school and elsewhere (Delta Dental of Ohio 2018). Delivering oral health care in school settings has the potential to reach many students who are at risk for oral disease and in need of care. Untreated oral disease affects students’ success in school and in life. Schools are logical places to educate students and families about the importance of oral health and to deliver a continuum of oral health services aimed at preventing oral disease and connecting students to ongoing community-based oral health care. School-based programs may stand alone or are integrated with other services, such as school-based health centers. They improve access to oral health care for students at high risk for oral disease; deliver preventive services, such as topical fluoride and dental sealants; improve OHL; connect students and families to a dental home; and build knowledge, skills, and habits for achieving lifelong oral health while helping families navigate community services.

In 2017, the Oral Health 2020 Network and the School-Based Health Alliance proposed a framework for organizing the partners, policies, programs, services, and curricula necessary to achieve better and more equitable oral health outcomes for people of all ages. The framework has five elements: oral health education, oral health screening, oral health preventive care, care coordination and linkage to community-based oral health care, and oral health treatment in schools (School-Based Health Alliance 2018). Schools with many low-income students now offer programs to prevent dental caries by using pit and fissure sealants to prevent dental caries in permanent teeth. These programs usually target students in the second and sixth grades to place sealants on first and second permanent molars, respectively. An effective school-based oral health program ensures that students who need treatment are referred to an oral health professional, receive services in a timely fashion, and establish an ongoing relationship with a dentist (that is, a dental home). Parents’ and caregivers’ OHL also play a major role in their ability to provide effective oral care for their children.

Oral health screenings conducted in schools can effectively identify students at risk for oral disease. Because parents and guardians are not present at the screening, screeners later provide them with information about their children’s oral health and any recommendations for follow-up. Ideally, school screening programs should follow up and track all referrals for further care by dental professionals (Association of State and Territorial Dental Directors 2008). Providing oral health education, screenings, preventive services, case management, and limited treatment in schools meets students and families where they are in a familiar setting. Although supervised toothbrushing programs have been successfully incorporated into preschool programs, such as Head Start, and have helped reduce caries (Kanellis 2000), such programs are not common in elementary schools, which means that a high-risk child whose risk was reduced in a Head Start brushing program could return to a higher caries-risk status upon entering elementary school. The long-term benefit in caries reduction attributable to these programs needs further study.

Interprofessional Care

Collaboration among health care providers can enable such providers to better serve many children affected by pediatric dental diseases and comorbid chronic health conditions. Interprofessional care (IPC) helps address a child’s comprehensive care—medical and dental—by involving the child, family members, caregivers, and providers from at least two disciplines in coordinated, patient-centered care that improves health outcomes (Mitchell et al. 2012; Graffunder and Sakurada 2016).

IPC models have been shown to reduce cost and errors, improve health outcomes, and decrease disparities while increasing access (Mitchell et al. 2012; Bambini et al. 2016; Navickis and Mathieson 2016; West and King 2019). They differ from traditional health care models in that they use innovative delivery approaches to coordinate care for patients with significant challenges. Health care providers, including dental professionals, must be trained to practice on IPC teams and to address some conditions outside their disciplines. Oral health educators on IPC teams are frequently safety net providers who support non-dental providers’ ability to recognize and monitor common dental diseases, such as tooth decay (Maxey et al. 2017). To date, evidence on effectiveness of some IPC care in terms of prevention and caries reduction remains limited (Chou et al. 2021).

Epigenetics Related to Growth and Development

Enormous recent advances in the field of genetics include mapping of the human genome, new technologies to identify and replicate genetic material, and the use of gene therapy to treat disease. A related field, epigenetics, deals with DNA modifications that lead to changes in gene expression but that are not part of the DNA sequence. Some DNA modifications are inherited, whereas others are influenced by environmental factors. The immediate effects of epigenetics in children are relevant to tooth development and craniofacial disorders with genetic causes and risks because of the importance of gene regulation during different developmental stages (Seo et al. 2015). One of the most exciting discoveries involves understanding how epigenetic regulation can control tooth-root patterning and development (Jing et al. 2019). Although the discoveries in this field generally arise from animal models, learning about the mechanisms and interactions of key proteins during tooth development could one day lead to the ability to regenerate a whole tooth.

Environmental Influences Related to Growth and Development

Epidemiologic and experimental data have suggested that teratogens—agents, such as cigarettes, alcohol, household and workplace products, and medications such as thalidomide and Dilantin—that can cause developmental malformations also can contribute to craniofacial anomalies (Wickstrom 2007; Murthy and Bhaskar 2009; Oginni and Adenekan 2012). In the past 20 years, awareness of per- and polyfluoroalkyl substances (PFASs) and their potential for negative health outcomes, including low birth weight and cancer, has been growing. These substances are synthetic chemicals used in manufacturing that leach into drinking water and accumulate.

Although many of these substances were phased out in 2002, the U.S. Environmental Protection Agency (2020) is developing a maximum-contaminant-level approach to help communities protect public health (Winkens et al. 2017; U.S. Environmental Protection Agency 2020). The most pronounced negative health effects from PFASs occur during exposure in pregnancy, infancy, and childhood (Winkens et al. 2017; Gyllenhammar et al. 2019), although preliminary research found no link between childhood PFAS exposure and dental caries (Puttige Ramesh et al. 2019). Environmental lead is another toxin with well-known adverse health outcomes as a result of exposure. Several studies (Gil et al. 1996; Moss et al. 1999; Gemmel et al. 2002; Kim Seow 2012) have suggested an association between lead levels and dental caries. However, other information suggests that dietary factors may confound this relationship and an independent association may not exist (Wu et al. 2019).

Our understanding of environmental and disease effects on tooth development has advanced, but our knowledge regarding the mechanisms through which these effects occur is still emerging, largely through advances in basic science (see Section 6). Trauma to the face and mouth is common, especially in children and young adults. Systemic and local disease and radiation (both therapeutic and environmental) have the potential to modify craniofacial development. Respiratory function also can affect facial development, but the relationship is not well understood. Similarly, jaw function or its absence can affect craniofacial development.

Gene Regulatory Network

Since 2000, new methods to document facial morphology, along with faster, less-expensive gene sequencing, have helped explain the contributions of genetic and environmental factors to normal craniofacial development and craniofacial anomalies. Genome-wide association studies have investigated the relationship between normal facial variation and single-nucleotide polymorphisms. The new methods have direct application to the oral-facial complex. For example, the PRDM16 gene is associated with Pax genes and plays a role in nose length and shape (Shaffer et al. 2016). The Hox family of genes represents an evolutionarily conserved group of transcription factors that are important in specifying regional identity and craniofacial patterning within the embryo (Deschamps and van Nes 2005). In addition, several well-characterized signaling pathways are involved in patterning of the jaw and the facial skeleton and in differentiation of neural crest cells. These include Sonic hedgehog, wingless-related, bone morphogenetic protein, and fibroblast growth factor (Ruiz i Altaba et al. 2002; Helms and Schneider 2003; Kimelman 2006; Minoux and Rijli 2010; Marcucio et al. 2011).

Dental Caries

Compared to previous generations, many children now experience improved oral health, but this picture is complicated. Among preschool-age children, the prevalence of dental caries increased from about 24% to 28% between 1988–1994 and 1999–2004, but returned to 24% in 2011–2014 (Figure 11). Although the prevalence of dental caries in preschool children appears unchanged since the 1999–2004 survey, digging deeper into the data reveals that this relatively flat trend was really an inverted “V-shaped” trend driven by boys. This unusual pattern of caries experience in primary teeth among children 2 to 11, has produced a cohort of children in which boys are experiencing significantly more dental caries than girls.

Figure 11

Percentage of children ages 2–11 with dental caries in primary teeth by age group and gender: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental caries in primary teeth (dft > 0).

However, there is some good news: a decade ago, the prevalence of dental caries in children aged 2 to 5 years living in lower-income households appeared to be on an upward trajectory, but recent data indicates that it has now declined (Figure 12). The most significant improvement in oral health status for preschool children in the past 20 years is the substantial decline in untreated dental caries. Overall, nearly 10% of children aged 2 to 5 years have untreated caries, whereas 19% had untreated caries 20 years ago (Figure 13). More important, these improvements are seen in preschool children across all racial and ethnic groups and family income levels, with larger declines in untreated caries benefiting minority and low-income children the most. This reduces long-established health disparities for this important oral health metric (Figures 14 and 15). American Indian and Alaska Native (AI/AN) preschool children also have experienced a small reduction in the prevalence of dental caries (55% to 52%) during the past decade (Phipps et al. 2019) and have experienced fewer untreated dental caries (39% to 34%). Indian Health Service (IHS) has attributed this improvement to the IHS Early Childhood Caries Collaborative, which focused on early access to care (first tooth, first exam), applying fluoride varnish four times per year, providing dental sealants to the very young, and implementing noninvasive restorative dentistry as early as possible.

Figure 12

Percentage of children ages 2–11 with dental caries in primary teeth by age group and poverty status: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of dental caries in primary teeth (dft > 0). (more...)

Figure 13

Percentage of children ages 2–11 with untreated dental caries in primary teeth by age group and gender: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental caries in primary teeth (dt > 0). (more...)

Figure 14

Percentage of children ages 2–11 with untreated dental caries in primary teeth by age group and poverty status: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of dental caries in primary teeth (dt > (more...)

Figure 15

Percentage of children ages 2–11 with untreated dental caries in primary teeth by age group and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental caries in primary teeth (dt > (more...)

For children aged 6 to 11 years, the prevalence of dental cavities in permanent teeth has declined significantly in the past 20 years, from 25% to 18%, irrespective of gender (Figure 16). This decline has mostly benefited children not living in poverty and those who are non-Hispanic White (Figures 17 and 18). For Mexican American children aged 9 to 11 years, a significant decline in dental cavities has occurred within the past decade as well (from 45% to 33%). Children living in higher-income households have seen significant decreases in caries experience, whereas those living in poverty have not (22% to 13% vs. 28% to 24%). This decrease in overall caries rates during the past 20 years disguises an increasing health disparity between children who live in poverty and those who do not.

Figure 16

Percentage of children ages 6–11 with dental caries in permanent teeth by age group and gender: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental caries in permanent teeth (DMFT > 0).

Figure 17

Percentage of children ages 6–11 with dental caries in permanent teeth by age group and poverty status: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of dental caries in permanent teeth (DMFT > (more...)

Figure 18

Percentage of children ages 6–11 with dental caries in permanent teeth by age group and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental caries in permanent teeth (DMFT > (more...)

Overall, untreated caries in permanent teeth has declined in the past 20 years; girls aged 6 to 11 years have experienced a steeper decline than boys (Figure 19).

Figure 19

Percentage of children ages 6–11 years with untreated dental caries in permanent teeth by age group and gender: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of untreated dental caries in permanent teeth (more...)

A decline in untreated caries among children aged 6 to 11 years living in less affluent homes has been substantial, especially since 2004 (Figure 20). Untreated dental caries among Mexican American and non-Hispanic Black children aged 6 to 11 years has also declined during this time period, and this decrease is most pronounced among those aged 9 to 11 years (Figure 21). Overall, this decline in untreated dental caries for children aged 6 to 11 years, like that in preschool children, indicates a reduction in some children’s oral health disparities.

Figure 20

Percentage of children ages 6–11 with untreated dental caries in permanent teeth by age group and poverty status: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of untreated dental caries in permanent (more...)

Figure 21

Percentage of children ages 6–11 years with untreated dental caries in permanent teeth by age group and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of untreated dental caries in permanent (more...)

The decline in the number of children with untreated dental caries has dramatically affected the proportion of untreated and filled tooth surfaces. Although the percentage of children aged 2 to 11 years with untreated dental caries in their primary teeth has decreased substantially in the past 20 years (from 23% to 15%), the mean number of dental surfaces in primary teeth affected by dental cavities has increased from 2.9 to 4.2 (Figure 22). This increase in decayed primary teeth surfaces has had a greater impact on boys than girls, and the difference is significant in boys and girls aged 6 to 11 (6.0 vs. 4.3 surfaces) (Figure 22). This relationship between decayed and filled tooth surfaces has become more evident among traditionally underserved or minority children during the past 20 years.

Figure 22

Mean number of decayed (ds) or filled surfaces (fs) of primary teeth in children ages 2–11 by gender and age group: United States, 1988–1994, 1999–2004, 2011–2014.

As the mean number of untreated tooth surfaces has declined significantly among children from low-income families and those of color, the mean number of treated surfaces has increased substantially in those same groups, suggesting improved access to care but also greater tooth decay experience (Figures 23 and 24). Although great strides have been made in reducing both the prevalence of untreated tooth decay and the number of tooth surfaces with untreated decay, these children still experience tooth decay in primary teeth at higher levels than non-Hispanic White children or those living in higher-income families.

Figure 23

Mean number of decayed (ds) or filled surfaces (fs) of primary teeth in children ages 2–11 by poverty status and age group: United States, 1988–1994, 1999–2004, 2011–2014. Note: FPG = Federal Poverty Guideline: < (more...)

Figure 24

Mean number of decayed (ds) or filled surfaces (fs) of primary teeth in children ages 2–11 years by race/ethnicity and age group: United States, 1988–1994, 1999–2004, 2011–2014.

Two decades ago, the proportions of untreated and filled primary tooth surfaces were approximately equal among children age 2–11; currently though, about 2 out of 3 tooth surfaces are now restored (Figure 25). Although this decline in untreated caries in primary tooth surfaces during the past 20 years has affected all children, regardless of gender, race and ethnicity, and family income, it has had a greater impact among preschool children (Figures 26 and 27). Two decades ago, 3 out of 4 tooth surfaces were untreated in children aged 2 to 5 years; currently among children in this age group, at least half of all tooth surfaces are restored (Figure 25). This improvement in the proportion of filled tooth surfaces has substantially benefited lower-income preschool children, essentially eliminating the disparity between this group and children living in higher-income households for this aspect of oral health (Figure 26). This proportional change indicates that children are receiving more dental treatment than 2 decades ago. However, it also suggests that efforts during the same time period to prevent new tooth decay have not yielded any promising results regarding children’s primary teeth.

Figure 25

Contribution of decayed (ds) or filled surfaces (fs) to the number of decayed and filled surfaces (dfs) of primary teeth in children ages 2–11 by gender and age group: United States, 1988–1994, 1999–2004, 2011–2014.

Figure 26

Contribution of decayed (ds) or filled surfaces (fs) to the number of decayed and filled surfaces (dfs) of primary teeth in children ages 2–11 by poverty status and age group: United States, 1988–1994, 1999–2004, 2011–2014. (more...)

Figure 27

Contribution of decayed (ds) or filled surfaces (fs) to the number of decayed and filled surfaces (dfs) of primary teeth in children ages 2–11 by race/ethnicity and age group: United States, 1988–1994, 1999–2004, 2011–2014. (more...)

During the past 2 decades, the mean number of tooth surfaces in the permanent dentition affected by tooth decay has changed little among children 6 to 8 years of age, and the proportion of surfaces untreated or filled has remained consistent as well (Figure 28). However, the mean number of dental surfaces affected by tooth decay has decreased significantly among children aged 9 to 11 years, especially for girls. When examining differences by poverty status, children aged 6 to 11 years living in households at 200% or higher of the federal poverty level experienced a decline in mean number of tooth surfaces affected by dental caries, whereas those living in poverty have experienced no change (Figure 29). Moreover, the proportion of untreated and filled tooth surfaces has remained fairly constant for these children. This outcome has increased the observed disparities in dental caries experience among children in the past 2 decades, and suggests that efforts to prevent tooth decay in newly erupted permanent teeth among children living in or near poverty are falling short and reflect an ongoing challenge.

Figure 28

Mean number of decayed (DS) or filled surfaces (FS) of permanent teeth in children ages 6–11 by gender and age group: United States, 1988–1994, 1999–2004, 2011–2014.

Figure 29

Mean number of decayed (DS) or filled surfaces (FS) of permanent teeth in children ages 6–11 by poverty status and age group: United States, 1988–1994, 1999–2004, 2011–2014. Note: FPG = Federal Poverty Guideline: < (more...)

Craniofacial Anomalies

In 1997, the National Birth Defects Prevention Network (NBDPN), a nationwide network of programs to facilitate birth defects surveillance and research, was founded. The establishment of this network has led to the first systematic collection, analysis, and dissemination of population-based birth defect information using surveillance data. Since the early 2000s, surveillance information has been used to produce national estimates of prevalence for orofacial defects.

In 2006, data pooled from 11 states showed that the national prevalence of cleft palate was 6.4 per 100,000 live births; that for cleft lip (with or without cleft palate) was 10.5 per 100,000 live births (Canfield et al. 2006). Similarly, in 2010, according to national estimates using 2004–2006 NBDPN data pooled from 14 state programs, the prevalence of cleft palate and cleft lip (with or without cleft palate) was 6.4 per 100,000 live births and 10.6 per 100,000 live births, respectively (Parker et al. 2010). Race/ethnic differences in craniofacial abnormalities continue, with the highest rates in non-Hispanic White and AI/AN babies. The rates of cleft palate without cleft lip per 100,000 live births were 6.4 for non-Hispanic White, 4.2 for non-Hispanic Black, 5.2 for Hispanic, and 6.5 for AI/AN babies from 1999–2007 (Canfield et al. 2014). Similarly, the rates of cleft lip, with and without cleft palate, per 100,000 live births were 9.7 for non-Hispanic White, 6.0 for non-Hispanic Black, 10.2 for Hispanic, and 20.1 for AI/AN births in that same time period (Canfield et al. 2014).

Orofacial developmental disorders also continue to be a challenge. Despite advances in understanding their causes, particularly their genetic basis, new approaches to treatment continue to lag. Tissue engineering, prenatal interventions, and microsurgery techniques remain underutilized in the care of children with these disorders. Thirty years ago, the lack of prospective studies hindered advancement of surgical innovation in this area (Roberts et al. 1991). In addition, techniques available today, such as three-dimensional imaging and microsurgery, were not available or sufficiently refined (Gattani et al. 2020). The need persists for ethical, well-designed prospective studies to validate these innovations. Nevertheless, as surveillance systems continue to improve with better reporting, our understanding of the epidemiology of craniofacial defects expands, and more targeted research can be implemented to identify areas for improvement in prevention and health services planning, which will improve quality of life for children affected by craniofacial disorders.

Developmental Tooth Defects (Dental Fluorosis and Other Defects)

A major challenge affecting our understanding of a range of developmental tooth defects and their impact on U.S. children is the paucity of recent epidemiological data regarding these conditions. Consequently, there is no accurate estimate of recent prevalence of developmental tooth defects in the United States.

Although the use of various fluoride modalities to prevent and control dental caries has been a topic of popular controversy for decades, new concerns involving the assessment of dental fluorosis have emerged since the 2000 Surgeon General’s Report on Oral Health. Efforts at measuring dental fluorosis have been inconsistent at the national level. Published findings from the 1999–2004 National Health and Nutrition Examination Survey (NHANES) reported an increase in dental fluorosis from the previous national assessment conducted in 1986–1987 (Beltrán-Aguilar et al. 2010). Later studies evaluating the 2011–2012 NHANES data suggested that the prevalence of dental fluorosis increased further (Wiener et al. 2018; Neurath et al. 2019), but subsequent analyses of examiner performance questioned this increase and suggested that the 2011–2016 NHANES fluorosis data may not be suitable for trends analyses (National Center for Health Statistics 2019). Consequently, an ongoing challenge is that contemporary policy making around this topic is dependent on data that are more than two decades old and with little consensus on how this condition should be assessed in the future.

Other Orofacial Conditions (Dental Erosion)

Dental erosion and tooth wear in children typically receive far less attention in the United States than in other countries. In the United States, dentists are incentivized to restore rather than monitor nonsensitive dental-erosive lesions for progression, which is important in managing acid exposure reduction. This relative lack of attention has led to knowledge gaps that have an impact on our understanding of the condition. Although other countries have developed consensus guidelines addressing diagnosis and management of dental erosion (O’Sullivan and Milosevic 2008; Loomans et al. 2017), and there is widespread adoption in Europe of the Basic Erosive Wear Examination Scale (Bartlett et al. 2008), there has been a lack of consensus in the United States about how to recognize, measure, and document dental erosion (American Dental Association 2018).

Although trend data regarding erosion are sparse, there is concern that erosive tooth wear is increasing among children and adolescents (Lussi 2006). The status of dental erosion in children, and its management, have remained essentially unchanged during the past 2 decades. This likely can be attributed to the focus on pediatric dental caries, which has a far more widespread impact on tooth destruction in youngsters.

Caregiver Oral Health Behaviors

Only a few interventions have been shown to exert a positive impact on parents’ attitudes, beliefs, and behaviors regarding their children’s oral health (Ismail et al. 2011; Wagner et al. 2014). Even when parents know what is best, this knowledge does not necessarily translate into practice. Almost 80% of parents and caregivers reported engaging in behaviors they knew were harmful to their children’s teeth, such as giving them juice or putting them to bed with a bottle of milk or juice (Hill et al. 2019).

Studies show that parental motivation and self-efficacy are associated with better child toothbrushing habits and healthier diets (Finlayson et al. 2007; Knowlden and Sharma 2015). However, despite early successes, clinical trials designed to increase parental motivation and self-efficacy to reduce the risk of early childhood caries (ECC) in high-risk children failed to reduce the incidence of caries (Batliner et al. 2018; Henshaw et al. 2018). Challenges remain for motivating parents to participate in caries-preventive behaviors (Bryant et al. 2016).

Dietary Behaviors

Our understanding about the adverse health effects of obesity and sugar-sweetened beverage (SSB) consumption in children has evolved substantially in recent years. New guidelines and policies have been implemented to help reduce the incidence of obesity, hypertension, diabetes, and tooth decay, all of which have a strong dietary component. Mentioned previously, these include guidelines from the American Academy of Pediatrics (AAP) on SSBs, including minimizing use of bottles and sippy cups for beverage consumption, not introducing 100% fruit juice before 12 months of age, and limiting juice to no more than 4 ounces a day for children aged 1 to 3 years (Heyman and Abrams 2017; Lott et al. 2019). Significant policy changes at the local, state, and national levels have restricted the availability of low-nutrient, high-sugar food and beverages at school as a consequence of the National School Lunch Program, the Supplemental Nutrition Assistance Program (SNAP), the Summer Food Service program, and the Afterschool Snack program, even though some of these programs have been cut (Roy and Stretch 2018).

Although the oral health workforce is trained to assess patient intake of added sugars and to recommend against it, they are generally not equipped to identify the complex factors influencing dietary behaviors and cannot recommend changes in a child’s overall dietary plan. In addition, dental providers generally are unfamiliar with programs that provide access to healthier foods. The U.S. Dietary Guidelines outline a model in which the education, health care, and industry sectors can help individuals with varying social and cultural norms learn how to make healthier food choices (U.S. Department of Health and Human Services and U.S. Department of Agriculture 2015). Although participation in interprofessional health care teams that include registered dietitians, psychologists, social workers, and pediatricians has the potential to change health behaviors and improve oral health outcomes, most pediatric oral health providers continue to provide dental care independent of collaborative care.

Multilevel Influences

During the past 2 decades, SDoH have been recognized as major contributors to oral disease, especially in children (Patrick et al. 2006; Fisher-Owens et al. 2007; Kim Seow 2012). This recognition has led, in part, to better understanding of numerous factors in a child’s background that can shape a child’s biology and behaviors related to oral health.

Much research on SDoH has focused on individual determinants of oral health, such as sociodemographic characteristics or behaviors (Link and Phelan 1995; Solar and Irwin 2010; Petersen and Kwan 2011). Although individual-based approaches to assessment and intervention are important, they are limited because they do not address variations in oral disease at the population level or the underlying causes of disease (Duijster et al. 2014; Fontanini et al. 2015; Singh et al. 2018). Population-level approaches can help to explain the complex and interactive causes of children’s health and oral health outcomes (Fisher-Owens et al. 2007; Lee and Divaris 2014), and emerging multilevel studies also can explicate the influence of different levels of social organization on oral health outcomes (Singh et al. 2018).

Child-Level Influences

A growing body of research during the past 20 years is showing that poor health and social circumstances can affect children for a lifetime. The damage can occur as early as the prenatal period. For example, gene transcription during fetal development in a mother under stress can produce lifelong negative outcomes (Kanherkar et al. 2014; Tiffon 2018). For preverbal children, too, exposure to adverse childhood experiences has a lifelong impact in ways as diverse as depression and suicide, interpersonal violence, sexually transmitted diseases, smoking and vaping, substance abuse, cancer, heart disease, and respiratory disease (Felitti et al. 1998; Hughes et al. 2017). The Commission on Social Determinants of Health regarded minimizing such challenges as an “ethical imperative” (Commission on Social Determinants of Health 2008).

In addition, intrinsic risk factors in children’s genetic makeup may require extra attention from the health system and family caregivers. Children with special health care needs (SHCN) often are at greater risk for oral health problems (Newacheck et al. 2000; Lewis 2009; Iida and Lewis 2012; Chi 2018) because of medication-related reduced salivary flow, behavioral challenges, muscle rigidity, poor access to care, and other factors (Newacheck et al. 2000).

Parent- and Family-Level Influences

Social structure and social environments influence parental behaviors, determining positive or negative oral health behaviors for parents themselves, as well as their children (Albino and Tiwari 2016). For example, studies have shown that in parents, better oral health is correlated with higher maternal education attainment and maternal self-care (Shearer et al. 2011; Heima et al. 2015; Phillips et al. 2016). Conversely, worse oral health is correlated with greater maternal stress, maternal smoking, unhealthy eating, and lack of clinical dental care (Masterson and Sabbah 2015; Phillips et al. 2016).

Parents can create an environment that directly influences children’s oral health behaviors by establishing and supervising toothbrushing, providing a healthy diet, and ensuring early visits to dental professionals (de Castilho et al. 2013). For example, children whose mothers supervise their toothbrushing have better oral health outcomes (Saied-Moallemi et al. 2008). Psychosocial constructs, such as attitudes, beliefs, and culture, also influence parental behaviors that, in turn, may affect parents’ oral health and that of their children (Reisine and Douglass 1998). Research has shown that parents who perceived fewer barriers and greater benefits to maintaining their children’s oral health and who understood susceptibility to caries have children with less caries experience (Kim Seow 2012; Tiwari and Albino 2017; Wilson et al. 2017; Batliner et al. 2018). Other psychosocial factors recognized as protective for pediatric oral health include higher maternal sense of optimism, positive coping strategies, resiliency, and confidence in one’s ability to self-control. These factors have been associated with increased parental participation in oral health promotion events, higher utilization of dental services, and caries-free status of children (Freire et al. 2002; Finlayson et al. 2007; Lindmark et al. 2011; Albino et al. 2014; Gururatana et al. 2014; Bryant et al. 2016; da Silva et al. 2018). Although numerous studies have assessed how SDoH affect children’s oral health, far fewer studies have examined how interventions can successfully ameliorate the oral health disparities related to economic and social inequalities in the United States.

To address ongoing challenges in health inequities, questions need to be asked about why an increase in the utilization of dental care does not lead to better outcomes among some pediatric populations, whether those are defined by race/ethnicity or by income level.

Cultural-Level Influences

In the past 20 years, the U.S. population has become more diverse, with at least 25% of all children (17.5 million children out of 70 million) living in immigrant households (O’Hare 2011; Zong et al. 2016), in which language and cultural practices are recognized as important influences on oral health (Butani et al. 2008; Tiwari and Albino 2017). Language and cultural differences have an impact on these children’s oral health behaviors and their use of services (Tiwari and Albino 2017). Interventions that recognize the complex interplay of these cultural and psychosocial factors are more likely to improve oral health knowledge, beliefs, and practices and have a long-term impact on the oral health of these children (Albino and Tiwari 2016).

One intervention that has demonstrated sensitivity to cultural factors and is increasingly being used by dental practitioners with the goal of impacting oral health behavior is motivational interviewing (MI). The MI approach involves person-centered, respectful communication designed to resolve ambivalence about behavior change and build intrinsic motivation for such change. MI has been used to successfully promote behavior change in brief medical encounters (Borrelli et al. 2007; Borrelli et al. 2016) and appears to be effective even for those who are not ready to change (Borrelli et al. 2017). Results of systematic studies related to the impact of MI on oral health outcomes, however, have been highly variable. A few studies have shown reductions in dental caries in children in some settings (Weinstein et al. 2004; Saengtipbovorn 2017; Wu et al. 2017; Colvara et al. 2018), yet only one large-scale controlled trial has produced these results—that one in an Australian Maori population (Jamieson et al. 2020).

Two major clinical trials of multi-year duration have demonstrated no such effects (Batliner et al. 2018; Henshaw et al. 2018). However, these and other studies have shown an effect of MI on oral health behaviors (Ismail et al. 2011) and oral health knowledge (Batliner et al. 2018; Henshaw et al. 2018), as well as improvements in oral health and diet and SSB consumption (Borrelli et al. 2015). Moreover, MI that targets caregivers has been readily accepted in some American Indian and Latino communities. Notwithstanding a number of limitations affecting the quality of evidence resulting from studies of MI interventions (Faghihian et al. 2020), the approach demonstrates considerable promise and is at least as effective as conventional dental health education in controlling tooth decay in preschool children.

There are still relatively large gaps in our understanding of cultural beliefs and practices related to oral health, owing to the lack of both qualitative and quantitative research in these areas. For example, although Hispanic/Latino children have increased their utilization of preventive dental care more than non-Hispanic White and Black children (Tiwari and Palatta 2019), their oral health outcomes have not been reflected by important reductions in oral health disparities (Dye et al. 2012). There also is a paucity of validated instruments for assessing the impact of culture on oral health. It is vital to develop standardized measures to assess cultural beliefs and practices related to oral health, particularly in populations experiencing the greatest burden of oral disease. Some recent efforts to develop and validate tools are gaining momentum (Wilson et al. 2014; Albino et al. 2018). The next step would be to design acceptable and effective prevention and treatment programs.

Community- and State-Level Influences

Influences at community and state levels affect children’s oral health, and some important advances have occurred in the past two decades. Increasing access to fluoridated water (Kumar et al. 2010; Aguiar et al. 2018), facilitating neighborhood dental health programs, expanding public insurance (Fisher-Owens et al. 2007), and implementing such policies as taxation of SSBs all function to improve children’s oral health outcomes. SDoH-mediated risk factors for poor oral health include interruption of SNAP benefits (Ostberg et al. 2017; Ettinger de Cuba et al. 2019), lack of preventive care in the community, lack of dental insurance, and a paucity of providers willing to accept public insurance (Lin et al. 2012). Public health strategies addressing oral health in children have to consider these underlying SDoH and will need community support to improve oral health in childhood and reduce inequalities in high-risk communities (Watt 2005; Phantumvanit et al. 2018).

Management of Dental Caries

Pediatric oral health has shifted its focus during the past 2 decades to recognize dental caries as a chronic disease process, with cycles of demineralization and remineralization of the tooth structure (Edelstein and Ng 2015; Fontana et al. 2018). This recognition transforms our ability to identify and manage dental caries using a person-centered, risk-based philosophy (Fontana et al. 2018). In addition, researchers have made strides in synthesizing the best evidence for disease prevention and management and making it accessible to providers. For example, the American Dental Association’s (ADA) Center for Evidence-Based Dentistry has published a series of guidelines on caries detection, prevention, and management to be used in clinical practice and to help identify knowledge gaps that will focus future research (Fontana et al. 2018; Slayton et al. 2018).

Policy efforts aimed at improving young children’s oral health have included introduction of the concept of the dental home (an ongoing relationship with a dentist) and the first dental visit at 1 year of age; expansion of the state Children’s Health Insurance Program (CHIP), which increased access to dental care for an additional 4 million low-income children; and the use of such interventions as fluoride varnish applications in medical offices, along with physician reimbursements for this service for Medicaid-insured children (Dye et al. 2017). These initiatives during the past 20 years most likely have contributed substantially to the significant reduction observed in untreated dental caries in children, particularly preschool children. Various U.S. Department of Health and Human Services agencies and state health departments have undertaken a number of other activities that have helped guide, initiate, and support policies and programs that have benefited children’s oral health (Crall and Vujicic 2020). These activities, as well as expansion of Federally Qualified Health Centers (FQHCs) that include dental clinics (see Section 4), have improved access to care for low-income children, which has resulted in the receipt of more dental services, including treatment for dental caries. Overall, these initiatives contributed to the prevalent view that both dental restoration in children and untreated decay have dramatically increased.

Important advances have been made to promote interprofessional collaboration to prevent ECC. A child who follows AAP’s schedule of recommended preventive health care would see a pediatric health care provider 15 times by their fourth birthday (American Academy of Pediatrics 2020). However fewer than 10% of toddlers typically have had a dental visit by age 2 (Bouchery 2013), which has accelerated efforts focusing on encouraging primary care providers to provide preventive dental care. Some studies show that early visits with medical providers result in lower rates of dental decay (Braun et al. 2017) and caries-related treatments (Pahel et al. 2011). Early preventive oral health visits in the medical home also have been shown to reduce health care costs (Stearns et al. 2012). Providing oral health care very early in childhood, with a strong focus on prevention, assessment of a child’s risk, surveillance to evaluate disease progression, and appropriate preventive and nonrestorative treatment for carious lesions, along with restorative treatment when indicated, is important in altering the caries disease process (Slayton 2015).

Policymakers and payers are promoting innovative quality-improvement approaches to reduce the incidence of caries. Local efforts that rely on the active engagement of families, risk assessment, reliable delivery of evidence-based care, and care coordination between medical and dental practices are emerging as community models for reducing incidence of dental disease (Ng et al. 2014; Crall et al. 2016). Risk-based protocols are being studied (Rechmann et al. 2018), and payers are beginning to experiment with risk-based benefit plans and value-based health plans (Martin et al. 2018). Because most individuals are unaware of these nontraditional alternatives to typical dental insurance plans, ADA has developed educational materials to encourage patient acceptance (Mark 2018). A typical health insurance plan is a contractual relationship among health providers, patients, and payers using a fee-for-service (FFS) payment model that focuses more on volume-driven health care services than value-based payment models, which focus more on quality, outcomes, and cost containment using health provider incentives to help inform the direction of care. Value-based care has been proposed to replace FFS, but implementation of successful models that reimburse providers for health outcomes rather than the amount of service units per patient or even the quality of those units remains challenging. Obstacles to a value-based care system may include provider indebtedness and financial commitments, lack of data, inadequate vertical data management systems, lack of educational emphasis, provider resistance, and payers’ reluctance to pilot extensive change. See Sections 1 and 4 for more information on value-based care.

Another important change in the past 20 years has been greater acceptance of minimally invasive techniques to manage tooth decay in young children. Procedures employing these techniques typically avoid the use of rotary dental instruments (drilling) and anesthesia (injections) to provide an interim restoration that is durable and controls the caries process. They range from atraumatic restorative treatment using glass ionomer filling materials to more traditional dental filling materials (such as composite resins and amalgam) to seal in the tooth decay under preformed stainless-steel crowns (the Hall technique). These dental caries management approaches provide several advantages over traditional restorative treatment options and are used globally in a variety of settings. Although evidence varies with regard to the success of these noninvasive alternate management techniques of tooth decay in young children, their effectiveness clearly depends upon the progression and severity of the tooth decay (Tedesco et al. 2018). Nevertheless, these noninvasive techniques challenge conventional approaches in the management of dental caries and provide alternatives to treat tooth decay in children safely and more efficiently.

Increasing the number of children who have no tooth decay also requires reducing risk for the disease, and this requires an accurate risk assessment. Unfortunately, challenges remain in implementing well-validated caries risk assessments. The strong performance of risk assessment models for preschool children appears to weaken as they grow older and progress into adolescence (Mejàre et al. 2014). An ongoing challenge in using risk assessment models in older children is a lack of data on how the risk-based approach impacts caries and patient-related outcomes (Fontana et al. 2020). Dental caries is a multifactorial disease, which means there are many elements to consider in creating a comprehensive caries risk assessment, including health history, biology, and behavior. Therefore, experts have concluded that the science of caries risk assessment would benefit from a better understanding of microbiological end points, salivary chemistry, and genomics (Dental Quality Alliance 2018a; Halasa-Rappel et al. 2019). In addition, evidence supports a strong association between dental caries burden in children and sociodemographic and community characteristics, such as income and race/ethnicity. However, algorithmic models are better at determining oral health outcomes at the population level, compared to the individual level (Gao et al. 2013; Divaris 2016; Halasa-Rappel et al. 2019). This disparity in model performance presents a challenge in translating population risk into individual risk; one that affects clinical decision making of oral health care providers and their patients.

Perinatal oral health and infant oral health care are important in preventing onset or progression of tooth decay in young children. Some infant oral care models, which focus on an approach tailored according to individual patient risk, have been promoted to prevent and manage ECC (Ramos-Gomez et al. 2012). Uncertainty remains concerning the use of some of these approaches, however—particularly with regard to the notion of risk modification. A panel of experts has identified 15 factors important in the assessment of caries risk, several of which are common to many assessment tools currently in use (Table 1). This panel has noted that the interactions among individual factors in modifying a patient’s risk remain largely understudied, and thus patients are being assigned much too subjectively into their risk-level group (Dental Quality Alliance 2018b). This subjectivity may challenge efforts focused on patient-centered care approaches for preventing and managing dental caries in children and should be addressed in future efforts. Although evidence linking caries risk to improved oral health is limited, it is important to educate patients and manage modifiable risk factors using the best available evidence (Fontana 2015; Dental Quality Alliance 2018b).

Table 1

Factors to consider when assessing risk for new dental caries in children.

Fluoride Agents for Dental Caries Prevention and Management

During the past 2 decades, the range of dentifrices available to consumers has dramatically changed. Today, several manufacturers offering toothpaste and other oral care products promote them as natural options to conventional oral care products. However, most of these natural products contain no fluoride, the critical anticavity ingredient of any product that is effective against caries (Walsh et al. 2019). Unfortunately, many parents assume that “natural” toothpaste also promotes good oral health. Improving the labeling of oral hygiene products for home use would give parents helpful information to make better-informed decisions. For example, toothpaste without fluoride could be labeled as “not proven to prevent cavities.” In addition, the labels for fluoride toothpaste could be updated with evidence-based information on proper dosage and safety for young children (Casamassimo et al. 2014). Nearly 2 in 5 children aged 3 to 6 years used more toothpaste than is recommended by the Centers for Disease Control and Prevention, and nearly 4 in 5 children aged 3 to 15 years started brushing later than recommended (Thornton-Evans et al. 2019). Among children aged 3 to 6 years, only about half used the age-appropriate, pea-sized amount of fluoride toothpaste (Thornton-Evans et al. 2019). Children ingesting more than the recommended amounts of fluoride are vulnerable to mild fluorosis later in childhood (Wright et al. 2014).

Since the early 2000s, more evidence has emerged to support the benefits from the application of fluoride varnish to prevent early-childhood caries (Weintraub et al. 2006). Subsequent to these studies, the U.S. Preventive Services (USPS) Task Force has found sufficient evidence for the benefits of early application of fluoride varnish to primary teeth by non-dental providers. In 2014, the USPS Task Force made a recommendation grade of “B” to support medical providers’ application of fluoride varnish to primary teeth (Moyer 2014). This recommendation is important because young children typically have multiple medical visits compared to dental visits. Consequently, pediatric and family health providers who care for young children often have the opportunity to provide preventive oral health services, including fluoride varnish applications. For example, children attending a community health center who had received at least four fluoride varnish applications by 3 years of age had a 20% lower prevalence of tooth decay than those who had not received fluoride varnish applications (Braun et al. 2017). In North Carolina, children who received at least four fluoride varnish applications in the medical setting had fewer caries-related treatments than children who received fewer treatments (Pahel et al. 2011).

Not only have fluoride varnish products evolved during the past 20 years, but their use has changed with a shift in the field of restorative dentistry to a more conservative, noninvasive approach to caries. As a preventive agent, 5% sodium fluoride varnish has been shown to be effective in reducing caries in children of all ages (Weyant et al. 2013). In 2018, ADA convened a panel of experts to develop evidence-based guidelines for nonrestorative treatment options for carious lesions. The panel’s report included recommendations on the use of fluoride varnish and other nonrestorative treatments to arrest and reverse noncavitated and cavitated lesions (Slayton et al. 2018).

Fluoride varnish is recommended for the treatment of noncavitated carious lesions either as a single agent or as part of the course of treatment combined with resin infiltration or sealant placement, depending on the lesion’s location. The recommended treatment option for cavitated carious lesions is 38% silver diamine fluoride, which is discussed further in Chapter 5.

However, some current findings are challenging the notion that fluoride varnish is effective in preventing tooth decay in preschool children’s primary teeth (de Sousa et al. 2019). Although debate continues on which fluoride varnish application protocols are most effective, it is clear that more than one application is necessary to prevent caries in children at mild to moderate caries risk (Lenzi et al. 2016). Variations in products and mode of use is a concern and may explain some of the variation in studies, as well as the underlying experience of the populations in which these products are used. Nevertheless, the challenge is getting fluoride varnish applied to the teeth of high-risk children whose parents’ insurance benefits do not provide coverage or who have persistent problems accessing dental care despite qualifying for Medicaid.

Dental Sealants for Caries Prevention and Management

In the past 20 years, the prevalence of children aged 6 to 8 years with at least one permanent molar sealed has more than doubled, from 14% to 31% (Figure 30). The largest gains, among Mexican American children and children living in poverty (an estimated fivefold increase), have nearly eliminated this health disparity among these groups (Figures 31 and 32). Similarly, the prevalence of dental sealants among children aged 9 to 11 years has increased from 29% to 53%, with large gains observed among low-income children and Mexican American children. This also represents a significant reduction in disparities for this health measure during the past 20 years.

Figure 30

Percentage of children ages 6–11 with dental sealants on permanent teeth by age group and gender: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental sealants is having at least one permanent molar (more...)

Figure 31

Percentage of children ages 6–11 with dental sealants on permanent teeth by age group and poverty status: United States, 1988–1994, 1999–2004, 2011–2014. Notes: Prevalence of dental sealants is having at least one permanent (more...)

Figure 32

Percentage of children ages 6–11 with dental sealants on permanent teeth by age group and race/ethnicity: United States, 1988–1994, 1999–2004, 2011–2014. Note: Prevalence of dental sealants is having at least one permanent (more...)

Although dental sealants have been used for decades to seal healthy occlusal surfaces to prevent dental caries, guidelines published during the past 20 years now support their additional use for application to posterior chewing surfaces, including those with noncavitated dental caries, in children and adolescents to stop tooth decay in its earliest stages (Wright et al. 2016). These ADA and American Academy of Pediatric Dentistry (AAPD) recommendations also advocate sealing primary molars in high-risk populations. During the past decade, other techniques have been introduced to seal off tooth decay. Resin infiltration permeates a small noncavitated carious lesion with dental material to prevent the tooth decay from further damaging the tooth (Faghihian et al. 2019). For larger carious lesions in which portions of the tooth enamel have been destroyed, permitting caries to progress into dentin, the Hall crown technique is sometimes used on posterior primary teeth. This minimally invasive intervention seals decay under a stainless steel crown using a self-curing glass ionomer cement, arresting the decay and achieving better long-term outcomes, compared with standard fillings (Innes et al. 2011; Ludwig et al. 2014).

Prevention and Management of Orofacial Pain

During the past 20 years, considerable knowledge has been gained regarding some areas of pediatric pain, leading to its recognition as a fifth vital sign. Much of this progress is related to the validation of pain assessment tools. Seminal papers, such as those by Finley and McGrath (1998) and O’Rourke (2004), outlined the use of scales such as the Face, Legs, Activity, Cry, Consolability pain scale. Garra and colleagues (2010) validated the Wong-Baker FACES^® pain rating scale (Wong-Baker FACES Foundation 2016) in emergency departments. In 2008, a government-industry collaborative established the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (Ped-IMMPACT) to identify core domains, assessments, and rigor for publications addressing pain in the pediatric population (McGrath et al. 2008). Cohen and colleagues (2008) noted that, despite its comprehensive scope, Ped-IMMPACT lacked substantial information on pain intensity, distress behaviors, and caregiver behaviors for all ages of childhood.

Provider organizations, such as AAP, AAPD, and ADA, have developed evidence-based guidelines on the use of pain medications in children (American Academy of Pediatric Dentistry 2020h). These guidelines focus on patient safety and make the critical connection lacking in Ped-IMMPACT, namely, linking behavior, pain, and procedural outcomes. This has resulted in the increased use of sedation in pediatric dentistry, including the use of general anesthesia, to provide definitive care for those children who cannot tolerate dental procedures in a typical dental office setting.

Prevention and Management of Dental Erosion

Our understanding of the prevention and management of dental erosion and tooth wear in children remains incomplete, with little change in the past 20 years. In general, there is a need to identify techniques that prevent dental erosion. There also has been a lack of knowledge about dental erosion among parents and caregivers in the United States, especially with regard to the potential irreversible loss of tooth structure from consuming acidic beverages, foods, and candies. This has been compounded by a lack of reimbursement for nutritional counseling to help children and their parents understand the potential for dental erosion from foods and beverages as well as erosion that results from acid reflux. There is a need for a more precise understanding of the role of exposure to dietary acid, gastric acid, and chlorine in children’s dental erosion, as well as the potential synergistic interaction with bruxism (teeth grinding). Another impediment is the cumbersome nature of communication between dentists and physicians when gastroesophageal reflux disease is suspected in youth with severe dental erosion. Other challenges include a lack of contemporaneous epidemiologic information in the United States on dental erosion and tooth wear to help identify population groups at risk and lack of a validated scale to track progression of dental erosion and tooth wear over time in clinical practice.

Pharmacologic Management of Children by Oral Health Professionals

Important changes affecting the pharmacologic treatment of children have occurred in recent years. Drug utilization is an integral part of the risk-benefit evaluation of therapies for children (Chai et al. 2012). In the past decade, recognition has been growing among oral health providers of the potential drawbacks to antibiotic overuse and opioid use. National trends show total prescriptions by dental providers decreased by 22% from 2009 through 2018, with 1.8 to 2.3 million prescriptions dispensed each year by U.S. retail pharmacies for children aged 1 to 10 years. (Analyses of these trends do not include medications administered or dispensed in other settings, such as oral surgery clinics and dental offices.)

Among patients 1 to 10 years, antibiotics were the drug class dental providers most commonly prescribed, followed by fluoride supplements and opioid analgesics (Figure 33). An estimated 64,000 prescriptions for opioid analgesics were dispensed to this age group in 2018, a 75% decrease from 261,000 prescriptions in 2009.

Figure 33

Ten-year proportion trend of retail prescriptions dispensed by drug class to pediatric patients ages 1–10 years prescribed by dental providers: United States, 2009–2018.

Before 2018, codeine/acetaminophen accounted for a large proportion of use in pediatric patients aged 1 to 10 years. However, in 2013, the FDA mandated the addition of a box warning and contraindication regarding the risk of respiratory depression and death with codeine use after tonsillectomy and/or adenoidectomy. In 2017, a contraindication was added to the labeling for codeine use alerting that codeine should not be used for the treatment of pain or cough in children younger than 12 years.

In 2018, FDA also required safety labeling changes for prescription cough and cold medicines containing codeine to limit the use of these products to adults aged 18 years and older. Dispensed prescriptions for codeine/acetaminophen written by dental providers for pediatric patients subsequently decreased substantially (U.S. Food and Drug Administration 2013; 2017; 2018).

Between 1999–2002 and 2011–2014, antibiotic use in children and adolescents decreased by almost half, predominantly in amoxicillin-containing antibiotics and cephalosporins (Hales et al. 2018). In the past 10 years, as prescriptions for antibiotics decreased for children and adolescents, the proportional distribution between children and adolescents has remained the same (Symphony Health PHAST™ Prescription Monthly Database Data extracted May 2019) (Figure 34). The distribution of retail prescriptions for fluoride supplements has shifted between 2009 and 2018; it decreased for children aged 1 to 10 and increased for adolescents aged 11 to 20 years. In 2009, about 60% of prescriptions for fluoride supplements were for children 10 years of age and younger.

Figure 34

Ten-year proportion trend of retail prescriptions for antibiotics by age group dispensed to patients ages 1–20 years prescribed by dental providers: United States, 2009–2018.

By 2018, fluoride prescriptions were more evenly divided between those 1 to 10 years of age (45%) and those 11 to 20 years of age (55%) (Figure 35). This shift may reflect changes in clinical practice and caries management that focus on early prevention efforts.

Figure 35

Ten-year proportion trend of retail prescriptions for fluoride supplements by age group dispensed to patients ages 1–20 years prescribed by dental providers: United States, 2009–2018.

Early Childhood Oral Health Programs

Following the release of the 2000 Surgeon General’s report on oral health, communities were encouraged to focus efforts on oral disease prevention and health promotion practices for families with young children (U.S. Department of Health and Human Services 2003). Many communities rose to the challenge, resulting in numerous programs across the United States to address oral health problems in children. Many of the programs are affiliated with public health, social service, or nutrition programs already in place, such as Head Start; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and other Maternal and Child Health programs.

Studies show that these programs have focused on oral health education, preventive services, and expanding the workforce to address oral health in early childhood (Rubin et al. 2018). Educational programs work with caregivers and address family-level health behaviors to prevent ECC. They target predominantly urban, low-income populations with approaches grounded in behavioral theory, caries risk assessment, and public health principles (Wysen et al. 2004), and some have incorporated pharmacologic treatments, such as fluoride varnish or silver diamine fluoride. A key component of these community-based and public programs is care coordination for families using multiple professionals, predominantly dental hygienists and dentists, as well as community health workers, including Head Start and WIC staff (Whittle et al. 2008; Brickhouse et al. 2013; Quinonez et al. 2014; Glatt et al. 2016; Ng and Fida 2016).

Head Start programs help parents obtain oral examinations and follow-up care for their children and support their understanding of the benefits of prevention and proper oral health care, along with the importance of establishing a dental home early in life (Head Start Bureau 2016). In the past 2 decades, Head Start programs have been encouraged to promote good dental hygiene in the classroom. During this period, the Administration for Children and Families enacted a national policy that requires once-daily, supervised toothbrushing for all children older than 2 years of age enrolled in Head Start programs (Office of Head Start 2006). Because children served by Head Start also are at increased risk for ECC, the policy ensures that this high-risk population is exposed to fluoride toothpaste at least 5 days per week.

School-Based Oral Health Programs and School-Based Health Centers

For some families, issues of cost, geography, and time create barriers that limit access to oral health care. One way progress has been made to address this is through school-based oral health programs, which are expanding to fill the gap by providing onsite oral examinations, cleanings, and treatment. The emerging field of teledentistry and the virtual dental home model also are exciting options for delivering much-needed preventive and early intervention services in schools (Glassman et al. 2012), and the increased reliance on teledentistry during the coronavirus (COVID-19) pandemic should yield important information on the benefits and limitations of this service.

There are several different mechanisms for providing dental services in schools. After Bassett Healthcare Network (an integrated health care system serving an eight-county region in rural upstate New York) identified oral health care as an unmet need for students, it prioritized adding this service to its 20 school-based health centers. Beginning in 2000, an elementary school nurse conducted oral health screenings and referred students at high risk for oral disease to an oral health professional in the community. By 2007, a dental hygienist and oral health coordinator were conducting oral health screenings in three additional schools. A full-time dentist now provides treatment to students in three centers with dental operatories. In addition, a team of dental hygienists travels to 20 school-based health centers to provide oral health education, screenings, and preventive services and to identify students requiring treatment. In addition, a nurse care coordinator helps families obtain care from the dentist affiliated with the school-based centers or another oral health professional in the community (Bassett Healthcare Network 2020).

Another example is Future Smiles, a nonprofit organization established by a registered dental hygienist in 2009, which offers oral health education, oral screenings, preventive care, care coordination, and treatment at little or no cost to more than 60,000 students at high risk for oral disease in Clark County, Nevada, schools (Chandler 2017). The organization’s mobile dental sealant program and Education and Prevention of Oral Disease high school site offer a range of preventive services as well as care coordination, connecting students with community-based dentists who provide free or reduced-cost restorative dental procedures.

Failure to anticipate challenges in establishing and operating school-based oral health programs can result in underutilization or closure of programs that provide valuable care to underserved children. Among the challenges frequently faced by proponents of school oral health programs are the following:

• Some states’ scope-of-practice laws require either an onsite dentist or a dentist’s prior examination and diagnosis before allowing a dental hygienist or other qualified oral health professional to provide services. In addition, some state Medicaid programs provide no reimbursement for preventive services delivered in school settings, and some state laws prohibit dental hygienists from billing Medicaid for services provided in school settings. See Section 4 for more detailed information on scope of practice laws.
• Getting consent forms signed and returned to school can be difficult. Having the active support of a school’s administration, health services team, teachers, and support staff is critical to facilitating the process.
• Ensuring treatment for students with urgent oral health needs is also critical. A case management protocol needs to be in place to serve students with urgent needs.

A more recent challenge affecting school-based oral health programs is the COVID-19 pandemic. Because these school-based programs are an essential access point for children to receive preventive oral health services, long-term disruption of these programs because of school closures may result in higher levels of dental caries for children dependent on these services for preventive care. This may disproportionately affect children from lower income and racial/minority groups (Tiwari et al. 2021). Conversely, the efforts made to connect stay-at-home students with schools, may contribute to teledentistry development and increased utilization in the future.

Interprofessional Care

Important progress has been made in interprofessional pediatric care among organizations, in practice, and in educational programs in recent years. FQHCs have grown in number. Increased funding for dental services and the opportunity for interaction between dental and medical providers within facilities because of proximity and shared electronic health records will lead to advances in collaborative care (Chang et al. 2019). Professional organizations such as AAPD and AAP have partnered on guidelines, such as those for sedation, and maintain ongoing liaisons (Coté and Wilson 2019). Pediatric medical and nursing curricula have added oral health (Hein et al. 2011), and correspondingly, dental and dental hygiene education have increased non-dental health content. As a result, there is a growing opportunity to evaluate the effects and benefits of interprofessional care on children’s health.

However, concerns about limitations in dental knowledge and ability remain common among physicians and non-dental professionals who participate in interprofessional care. With appropriate training, however, these non-dental providers can identify dental caries risk and dental disease in children and make appropriate referrals for dental treatment (Bader et al. 2004; Bernstein et al. 2016). Children who receive referrals from primary care providers are more likely to have a dental visit (Bader et al. 2004; Bernstein et al. 2017). Interprofessional care has the potential to deliver coordinated care, especially to youth with complex health needs. Although ineffective communication and minimal collaboration continue to contribute to fragmented patient care that can lead to poor patient outcomes, efforts at improving collaboration and communication are increasing within interprofessional education across the health disciplines (Lapkin et al. 2013; Harnagea et al. 2017; Walker et al. 2018).

Dental Caries

In the past decade, progress has accelerated in the biological and molecular understanding of processes underlying dental caries. Moreover, whole-genome investigations of dental caries may further expand our understanding (Morelli et al. 2020). Specific risk loci for childhood and adult dental caries have been reported, although the evidence on this front is still developing (Shaffer et al. 2011; Haworth et al. 2018; Shungin et al. 2019). The genetic influence on caries is reportedly more prominent in children than in adults, perhaps because of mitigating biological and other factors later in life (Shaffer et al. 2011; Ballantine et al. 2018). Molecular studies of the caries-associated oral microbiome (Dewhirst et al. 2010; Tanner et al. 2011; Nyvad et al. 2013; Richards et al. 2017), its biogeography (Mark Welch et al. 2016), and its metabolome (Zandona et al. 2015) have generated additional scientific insights. Taken together, in the future, these scientific advances may lead to better preventive, diagnostic, risk assessment, and therapeutic applications, with better oral health for all children (Casamassimo et al. 2014).

Craniofacial Anomalies

Specific genetic factors cause some craniofacial anomalies, but the causes of others remain unknown. Early genetic screening of parents allows them to prepare for children who may require surgical and behavioral interventions early in life (Hart and Hart 2009; Yoon et al. 2016). Identifying and avoiding known teratogens (agents that cause birth defects) during pregnancy and avoiding trauma, preventable disease, and radiation all can reduce hereditary and acquired craniofacial problems.

The continued discovery of genetic, epigenetic, and environmental contributors to craniofacial development, as well as research on stem cells and tissue regeneration, will drive new procedures for prevention and therapy. Fetal surgery may offer some solutions for significant anomalies. Gene therapy may one day create minimally invasive or nonsurgical ways to correct craniofacial anomalies, greatly improving quality of life for patients who now face multiple, costly, and intensive procedures. Although protocols for care exist for several conditions, future care will require more detailed analysis and individualized planning by a multidisciplinary team focused on clear treatment goals, quality of life, and overall well-being.

Dental Sealants

Removing practitioner-based barriers as to who can apply dental sealants to children’s teeth can enhance utilization and improve access to this valuable preventive treatment. Some states already have amended their practice acts to allow dental hygienists to provide sealants under the general supervision of a dentist, and other states are considering similar actions to allow hygienists to apply sealants through public health programs. Additional actions that could accelerate the adoption of these policies include funding the expansion of school-based programs that target at-risk children, eliminating legal barriers that use age and tooth restrictions to bar reimbursement, increasing Medicaid reimbursement rates, and providing reimbursement incentives for dentists to participate in public insurance programs.

Silver Diamine Fluoride

In recent years a product containing 38% silver diamine fluoride (SDF) has become commercially available to providers in the United States. SDF was used in other countries (including Australia and China) to arrest dental caries for many years (Li 1984; Gotjamanos 1996) before its introduction into the United States in 2014. SDF has gained increasing acceptance as evidence emerges for its efficacy in arresting progression of cavitated lesions in children and adolescents (Slayton et al. 2018). Although staining of treated cavities is an issue, SDF’s noninvasive nature and cost-effectiveness make it an important option for children, including those with special health care needs and those who face barriers to accessing dental care (Crystal et al. 2017; Johhnson et al. 2019; American Academy of Pediatric Dentistry 2020k).

The silver in the SDF compound is a short-term antimicrobial agent that inhibits proteolytic enzymes in dentin. Because of that antimicrobial action combined with fluoride’s remineralization properties, SDF shows great promise for managing cavitated lesions (Duangthip et al. 2018). However, use for this purpose is off label according to the U.S. Food and Drug Administration regulations, and general dentists have been slower than pediatric dentists to begin using it. The uses of SDF continue to expand. At publication, limited studies suggest that beyond its caries-arresting benefit, SDF also may act to prevent new caries (Sorkhdini et al. 2020), offering an additional benefit to patients at high risk or already afflicted with caries. Through teledentistry, SDF is being used as a therapy provided by expanded-duty dental personnel to reach previously underserved populations and those for whom traditional care is not an option because of health concerns, distance, and isolation requirements (Cripe 2020).

As SDF use increases, opportunities for prevention and modified treatment using combinations of SDF and traditional restorative care will continue to emerge. More insurance plans can also be expected to cover SDF as its use expands, which may encourage broader training of oral health professionals in its use.

Early Childhood Oral Health Programs

Efforts to translate research findings into reduced rates of ECC and improved oral health are moving more interventions from dental offices to community-based settings, such as schools, where it is possible to reach many more people at high risk for oral diseases. These promising moves require partnerships among health care providers, health care settings, and nontraditional organizations, such as Head Start and WIC Centers, public housing authorities, public school systems, and food pantries. Community-based interventions of this type have potential as more cost-effective strategies to reduce ECC and eliminate oral health disparities, and thus warrant further exploration (Garcia et al. 2015).

The emerging development of pediatric oral health registries has the potential to provide valuable quality improvement information to promote patient-provider engagement and shared decision making. Such registries also generate actionable data to use in improving quality of care and outcomes at the individual and population levels (Rozier et al. 2003; Ng et al. 2014; Kakudate et al. 2015; Ramos-Gomez et al. 2017; Fisher-Owens and Mertz 2018; Ruff et al. 2018). Collectively, there has been a lack of reporting on the various pediatric oral health programs. Such reporting could identify best practices and create collaborations to benefit children and families most affected by oral health disparities. Pediatric oral health programs are now found in early childhood programs, medical and dental care integration programs, and foundations and nonprofit organizations, as well as in advocacy and policy organizations, ECC collaboratives, and resource centers.

An example of the integration of digital health into dentistry is the MySmileBuddy Program led by Columbia University, which brings preventive oral health intervention to urban families through technology. This program used an electronic tablet (Apple iPad) to assist community health workers to interact with poor, minority, low-literacy parents of young children to evaluate a child’s risk for ECCs and to provide information promoting oral health (Levine et al. 2012; Lumsden et al. 2019).

Other promising strategies for optimizing oral health care delivery for young children include early establishment of a dental home, risk-based approaches, and integration of dental and medical care (Hale 2003; Crall 2005; Ramos-Gomez et al. 2010; Mouradian et al. 2014). There is evidence that Federally Qualified Health Centers and primary medical care practices improve access to, and quality of, oral health care for children (Bernstein et al. 2016; Crall et al. 2016; Atchison et al. 2018). But some barriers to achieving successful medical-dental practice integration remain, including a need to enhance dental facilities, including adding appropriately trained personnel and advanced information technology to support care coordination and integrated health records. In addition, practice management and technical assistance are needed to support staff (Close et al. 2010), and ongoing training is needed for providers and their staff in key clinical areas such as caries risk assessment, risk-based approaches to prevention and disease management, and family-centered care for diverse populations. This area of pediatric care is constantly evolving, and the future looks promising as new practices emerge that will improve children’s oral health.

Interprofessional quality improvement learning collaboratives have been shown to improve the practices of medical and dental personnel and clinic administrators (Rozier et al. 2003; Ng et al. 2014; Quinonez et al. 2014; Braun and Cusick 2016; Braun et al. 2017). Other innovations that can further oral health integration are smartphone applications that help community health workers provide caries risk assessment, engagement, and referral in ways acceptable to the communities they serve (Chinn et al. 2013).

Interprofessional Care

Most low-income children regularly receive medical care. Ninety percent of children younger than 6 years received well-child visits in 2017 (Child Trends Databank 2018), which provide opportunities to deliver oral health services. Several implementation studies and related work have provided a roadmap for strengthening interprofessional care for children. For example, an initiative supported by the Health Resources and Services Administration, the Integration of Oral Health and Primary Care Practice, provides a framework for the successful integration of oral health with primary care through five domains of clinical activities and competencies (Maxey 2014): risk assessment, oral health evaluation, prevention intervention, communication and education, and interprofessional collaborative practice.

Interprofessional care in primary care offices, pediatric medical offices, hospitals, and community-based settings, such as Head Start, now address children’s medical, dental, and other needs in the settings where they are most likely to access care. Two keys to further success will be further development of an integrated electronic health record and expansion of telehealth beyond the few states that currently allow it to include the provision of dental services. The expansion also would include the participation of third-party payers.

Safety net clinics have become models for interprofessional care and increased access to oral health care (Bernstein et al. 2017). Combining medical and dental care in the same setting makes resources more readily available to address language barriers, including translators to discuss oral health care. Practically speaking, combining medical and dental care in safety net settings also limits the hardship that multiple appointments place on parents. Even though co-location of medical and dental services is a promising new direction, it does not guarantee coordinated care or promotion of preventive services (Horowitz et al. 2014), and these models will require careful implementation to achieve full benefits.