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AAP, Canadian Paediatric Society update policy on oral care of Indigenous children

May 17, 2021

Silver diamine fluoride can decrease or arrest caries progression but causes staining. Courtesy of Daniel Raether, D.D.SIndigenous children of Canada (First Nations, Inuit and Métis) and the United States (American Indian/Alaska Native) have a higher prevalence of early childhood caries (ECC) and more severe disease compared to the general child population of both countries. Furthermore, ECC begin at an earlier age in Indigenous children.

Surveys show that 75% of AI/AN children ages 3 to 5 years have ECC. In many communities, the caries rate is more than 90% — five times greater than that of the general U.S. child population. In addition, many AI/AN children need operative repair, which is expensive and carries the risks associated with general anesthesia.

Although general guidelines on oral health promotion and caries prevention exist, the different epidemiology, severity of dental disease and barriers to care in Indigenous communities require special consideration. Pediatricians need to recognize that “2 is too late” for preventive interventions in Indigenous children to be successful and that new, earlier interventions are needed.

In response, the AAP has updated the policy statement Early Childhood Caries in Indigenous Communities from the Committee on Native American Child Health, Section on Oral Health and the Canadian Paediatric Society. It is available at and will be published in the June issue of Pediatrics.

The policy addresses community-based health-promotion initiatives and access to dental care for Indigenous children. It encourages interventions at early ages and referral to dental care for sealants, interim therapeutic restorations and silver diamine fluoride.

The policy also recommends augmenting the dental workforce in Indigenous communities and encourages further research on the microbiology, epidemiology and management of ECC in these populations.


Suggestions for clinicians caring for AI/AN children include the following:

  • Promote exclusive breastfeeding for the first six months and breastfeeding until 12 months of age.
  • Discuss oral health, assess caries risk and provide anticipatory guidance on oral hygiene and diet during well-child care visits starting with the first tooth eruption.
  • Recommend the establishment of a dental home by 12 months of age.
  • Promote supervised twice-daily use of fluoridated toothpaste beginning with the eruption of the first tooth.
  • Provide fluoride varnish by dental or nondental health care providers in primary care settings and by trained lay workers in other settings starting with the first tooth eruption (and every 3-6 months thereafter).
  • Promote the use of silver diamine fluoride for Indigenous children with ECC to decrease caries progression and avoid the need for operative repair under general anesthesia.
  • Promote the incorporation of interim therapeutic restoration into caries management protocols.
  • Promote the use of sealants on primary molars to prevent caries and the need for operative repair.

In addition, pediatricians can advocate for the following:

  • Changes in Indigenous communities to reduce frequent consumption of sugary drinks and snacks.
  • Water fluoridation in Indigenous communities.
  • Development of an adequate dental workforce that can include the training and use of professionals such as dental therapists.
  • Increased representation of Indigenous people in oral health professions.
  • Education for dentists, dental hygienists, dental therapists and assistants working in Indigenous communities so they can practice in a culturally appropriate manner.
  • Community-based participatory research on the epidemiology, prevention, management and microbiology of ECC and ECC-prevention projects in Indigenous communities.

Dr. Holve is a lead author of the policy statement and a consultant to the AAP Committee on Native American Child Health. He is the former chief clinical consultant in pediatrics for the Indian Health Service.

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