Implementation of oral health evidence-based practices in early care education settings across the U.S. during different COVID-19 periods

Implementation of oral health evidence-based practices in early care education settings across the U.S. during different COVID-19 periods | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Implementation of oral health evidence-based practices in early care education settings across the U.S. during different COVID-19 periods View ORCID Profile Phoebe P. Tchoua , Shreena Patel , Aviva Shira Starr , View ORCID Profile Richard Rairigh , Falon Smith , View ORCID Profile Erik A. Willis doi: https://doi.org/10.1101/2025.04.09.25325529 Phoebe P. Tchoua 1 Center for Health Promotion and Disease Prevention The University of North Carolina at Chapel Hill , Chapel Hill, NC 27514 Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Phoebe P. Tchoua For correspondence: ptc{at}unc.edu Shreena Patel 1 Center for Health Promotion and Disease Prevention The University of North Carolina at Chapel Hill , Chapel Hill, NC 27514 Find this author on Google Scholar Find this author on PubMed Search for this author on this site Aviva Shira Starr 1 Center for Health Promotion and Disease Prevention The University of North Carolina at Chapel Hill , Chapel Hill, NC 27514 Find this author on Google Scholar Find this author on PubMed Search for this author on this site Richard Rairigh 1 Center for Health Promotion and Disease Prevention The University of North Carolina at Chapel Hill , Chapel Hill, NC 27514 Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Richard Rairigh Falon Smith 1 Center for Health Promotion and Disease Prevention The University of North Carolina at Chapel Hill , Chapel Hill, NC 27514 Find this author on Google Scholar Find this author on PubMed Search for this author on this site Erik A. Willis 1 Center for Health Promotion and Disease Prevention The University of North Carolina at Chapel Hill , Chapel Hill, NC 27514 Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Erik A. Willis Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Objective To describe the implementation of oral health evidence-based practices in early care education (ECE) centers enrolled in the web-based Go NAPSACC program pre-, during, and post-COVID- 19 stay-at-home (SAH) orders. Methods Retroactive data from three types of programs (n=2,018), who participated in Go NAPSACC oral health modules, Head Start (n=215), family child care home (FCCH; n=688), and center- based (n=1,115) were analyzed for evidence-based practices (EBP) met. EBP total and EBP met percent scores are reported. Results We found significant differences in oral health EBP total and EBP met percent scores between program type (p<0.001). Head Start programs had statistically significant higher EBP total percentage scores (81.8, 95% confidence interval [CI] = 78.5, 85.2; p<0.0001) than FCCH (69.5, 95% CI = 67.1, 71.8; p<0.0001), and center-based (59.5, 95% CI = 57.3, 61.7) programs. Head Start programs also had statistically significant higher EBP met scores (62.0, 95% CI = 57.7, 66.3; p<0.0001), than FCCH (49.7, 95% CI = 46.7, 52.7; p<0.0001), and center-based (36.9, 95% CI = 34.1, 39.8) programs. We observed no statistically significant differences among programs based on SAH order period for neither EBP total percentage scores (period, p=0.761; interaction between program type and period, p=0.788) and EBP met scores (period, p=0.178; interaction between program type and SAH order period, p=0.293). Conclusions All ECE programs struggled to meet oral health evidence-based practices during three COVID- 19 SAH periods. SAH orders did not explain the difference observed across the three programs. Introduction Early childhood caries (ECC) is the most common chronic disease in American children and poses a significant risk to the general health of children, affecting 21.4% of children 2-5 years old ( 1 , 2 ). According to the American Academy of Pediatric Dentistry, ECC is classified as the “the presence of 1 or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth” in children under six ( 3 ). Through health promotion practices that focus on foods provided, oral hygiene, fluoride use, access to dental care, caregiver education, and feeding practices, most ECC are preventable ( 4 ). Developing and encouraging proper oral care routines in infancy and early childhood sets the groundwork for long-term oral health ( 2 ). In 2019, 62% of American children who received weekly non-parental care were enrolled in out- of-home early care and education (ECE) programs ( 5 ), with children under age five spending an average of 24 hours per week in these settings ( 6 ). During this time, children often consume significant portions of their daily meals, which can include up to two meals and two snacks ( 7 ). Given the substantial role ECE programs play in children’s daily routines, they are uniquely positioned to promote oral health and prevent ECC. By implementing effective organizational policies, practices, and oral health promotion strategies, ECE settings can help establish healthy habits that support long-term oral health for all children in their care ( 8 ). A review of state regulations revealed significant gaps in oral health policies across six key categories: screening for dental care needs, referral for dental care, storing toothbrushes, tooth brushing, fluoride use, and oral health education. Fifteen states lacked any regulations, 23 states had only one regulation, and 13 states had more than one regulation ( 9 ). Additionally, oral health practices also vary between state-funded and non-state-funded ECE programs ( 10 ). Non-state- funded programs reported higher rates of oral health education (55% vs 39%) and oral health practices (85% vs 68%), whereas state-funded programs were more likely to include routine toothbrushing (46% vs 21%) ( 2 , 11 ). These discrepancies in policies and practices led the American Academy of Pediatric Dentistry to issue a policy statement urging ECE settings to adopt standardized oral health guidelines. Their recommendations aim to minimize the risk of ECC by emphasizing dental disease prevention and oral health promotion ( 11 ). The COVID-19 pandemic disrupted many health practices across the US, including oral health practices in ECE settings. In 2020, parents were 16% less likely to perceived their children’s dental health as excellent than 2019 ( 12 ), and reports of poor dental health increased by 75% ( 12 ). ECE programs faced significant challenges, including temporary and permanent program closures and decreased enrollment, that made it difficult for programs to operate effectively ( 13 ). These disruptions impacted not only the sustainability of programs but also the continuity of care and education for young children. The decline in oral health and the operational challenges faced by ECE programs are closely interconnected. To mitigate the risk of COVID-19 transmission, many routine oral health practices within these settings were either halted or significantly modified. For example, a COVID-19 Head Start policy suspended tooth brushing in classrooms - a practice previously required in many programs ( 14 ). This action, though crucial for minimizing the risk of COVID-19 transmission, may have inadvertently impacted the oral hygiene habits of young children. This study aims to address critical gaps in understanding how the implementation of oral health practices in ECE settings have evolved over time, particularly in response to the disruptions caused by the COVID-19 pandemic. Given the significant role ECE programs play in supporting young children’s health and the notable variability in oral health policies and practices across states and program types, it is essential to evaluate how these settings adapted to pandemic- related challenges. Understanding the extent to which oral health practices were maintained, modified, or discontinued during key stages of the pandemic can inform future strategies to promote oral health in ECE environments. Moreover, insights gained from this study will help identify areas where additional support, training, or policy changes are needed to ensure that ECE programs are equipped to sustain effective oral health practices. This work is particularly relevant for guiding the continued implementation of evidence-based health promotion programs to improve child health outcomes. METHODS The data for this cross-sectional study are from ECE programs enrolled in the web-based Go NAPSCC program ( gonapsacc.org ) from July 2014 to February 2024 and was collected on September 3, 2024. Go NAPSACC, an evidence-based health promotion initiative for ECE settings, helps programs implement evidence-based practices across seven health modules, including oral health. There are 11,431 ECE programs registered with Go NAPSACC across 23 states. ECE programs not utilizing the Oral Health module (n=9276) and those determined to be duplicate registered programs (n=74) were excluded. Due to low enrollment of school-based ECE programs (n=63) we limited this analysis to only those that were classified as Head Start (n=215), family child care homes (FCCH; n=688), or center-based (n=1,115) resulting in an analysis cohort of 2,018 ECE programs. Using a repeated cross-sectional design, self- assessments completed during three time periods corresponding to key times of the COVID-19 epidemic in United States: ( 1 ) pre-SAH order; ( 2 ) during SAH order; ( 3 ) post-SAH were included in the analysis. This study analyzed available organizational level data with no individual level identifiable personal information, therefore ethics approval and informed consent were not required. Program Characteristics Program data are self-reported by ECE administrators through the online system. Administrators report program type (e.g., Head Start, center-based, FCCH), association (e.g., faith-based, military), Child and Adult Care Food Program (CACFP) participation, care type (full-/half-day), ages served, ages provided meals, subsidies received, years in operation, and number of children enrolled. Oral Health Evidence-Based Practices Evidence-based practice recommendations around oral health were created through extensive reviews of the scientific literature, authoritative recommendations (e.g., Office of Head Start, American Dental Association, American Academy of Pediatrics (AAPD), Caring for our Children, and Oral Health expert opinion). These recommendations were used to create a self- assessment tool completed by ECE administrators and are scored using a 4-point Likert-type scale, from 1 = “not engaging”, 2 = “minimally engaging”, 3 = “somewhat engaging”, to 4 = “fully engaging” in evidence-based practice recommendations. The oral health module consisted of 25 questions under five evidence-based practice domains: tooth brushing (six questions), food and beverages provided (five questions), teacher practices (six questions), education and professional development (seven questions), and policy (one question). Tooth brushing domain asked questions on time allocated for toothbrushing per week, how the toothpaste is distributed, toothpaste availability, and frequency of use of fluoride toothpaste. Food and beverages domain asked questions on how often high sugar foods, flavored milk, 100% juice, and regular juice were offered (i.e., daily, weekly, or monthly), and how water was made available (i.e., upon request, freely available, visibly accessible, offered indoors or outdoors). Teacher practices domain asked questions on whether bottles or sippy cups were offered to infants and toddlers (i.e., at naptime or playtime), level of tooth brushing assistance teacher provided to children, and whether teachers offer praise and a positive environment during tooth brushing sessions. Education and professional development domain asked questions on how often teachers use planned oral health education in their lessons, receive professional development, provide families information on the child’s oral health throughout the year, and spoke to children about the importance of oral health indirectly. Policy domain asked a question to assess the ECE program’s written policies on oral health. Evidence-based practice score Evidence-based practice (EBP) total scores are calculated by summing all scored items in the self-assessment divided by the total possible points for all applicable items and the total is multiplied by 100, yielding a percentage score between 0 (least engaging) to 100 (most engaging). Percentage of evidence-based practices met EBP met percentage score is calculated by summing the number of items in the self-assessment where the best practice was fully engaged (score = 4) and dividing this number by the total number of evidence-based practices and the total is multiplied by 100, yielding a percentage score between 0 (not fully engaging) to 100 (fully engaging). The EBP total score and EBP met percentage score helps measure the full range of ECE program’s engagement in evidence-based practices. SAH order data source Retrospective data was obtained from individual state-maintained websites to identify the exact dates when SAH orders were enacted for each state. Data collected prior to this date were classified as pre-SAH order period. Data collected between the date of the SAH order (between March 4, 2020, and April 7, 2020) and August 4, 2021 (the date when the Office of Head Start lifted its toothbrushing suspension in ECE programs), was classified as during the SAH order period. Any data collected after August 4, 2021, was classified as post-SAH order period. Statistical analyses Data were summarized using means and standard deviations for continuous variables, and frequencies and percentages for categorical variables. If a program had more than one oral health self-assessment, their first completed self-assessment was used in the analysis. Generalized linear mixed models (SAS PROC MIXED) were used to compare evidence-based practice and percent of evidence-based practices met scores between program type (i.e., Head Start, FCCH, center-based) across SAH periods. Models included fixed effects for program type, SAH order period (pre, during, post), program type*SAH interaction, and Go NAPSACC registration date. Random effect for the state the ECE program resided was included to account for correlations among programs operating within in the same state. Models included a subject-specific random effect and accounted for the clustering of ECE programs within the same state. Statistical significance was determined at 0.05 alpha level, and all analyses were performed in spring 2024 using SAS version 9.4 (SAS Institute Inc., Cary, NC). RESULTS Most Go NAPSACC programs were center-based (n=796, 53.4%) with no program association (n=1,282, 86.0%). They were predominantly located in metro areas (n=1,032, 69.3%), participated in CACFP (n=1,025, 68.8%), and operated full-day (n=1,434, 96.2%). These programs served children aged 0-5 years and had been in operation for an average of 19.2 years (SD = 15.4). See Table 1 View this table: View inline View popup TABLE 1. Participant Characteristics by three key periods of the COVID-19 Pandemic. Oral health module during SAH periods ECE programs were impacted in various ways pre-, during-, and post-SAH periods. During the SAH period, the number of Head Start programs initiating the oral health module decreased (14.8% to 13.4%) and remained low post-SAH (4.9%). Conversely, the number of FCCH programs initiating work on oral health increased (28.7% to 34.9%) and remained high (43.5%). Center-based programs experienced less fluctuation in oral health work (56.6% to 51.7% to 51.6%). The location of ECE programs also played a factor in those choosing to work on oral health promotion. While work on the oral health module in rural programs increased (2.0% to 3.1% to 5.3%), urban environments experienced an initial decrease (29.0% to 24.9%) that rebounded post-SAH (26.6%). Evidence-based practice total score Mean EBP total percentage scores by program type and SAH order period are presented in Fig 1 . Across all three periods, Head Start programs had the highest EBP total percentage score (82.37%, 82.34%, 80.83%), followed by FCCH programs (70.0%, 69.74%, 68.67%), and lastly center-based programs (59.96%, 58.62%, 59.86%). Further analysis showed a significant difference in oral health evidence-based practices scores between program type (p<0.001). Specifically, center-based programs had significantly lower scores (59.5, 95% confidence interval [95% CI] = 57.3, 61.7) than both Head Start (81.8, 95% CI = 78.5, 85.2; <0.0001) and FCCH programs (69.5, 95% CI = 67.1, 71.8; <0.0001). However, there were no statistically significant differences observed among programs based on SAH order period (period, p = 0.761; interaction between program type and period, p = 0.788). Download figure Open in new tab Fig 1. Oral health evidence-based practice scores across different early childhood education program types during three key periods of the covid-19 pandemic Evidence-based practice met percentage score No program fully met the EBP recommendations (i.e., scored 100%). The EBP met percentage scores by program type and SAH order period are presented in Fig 2 . Like EBP total percentage score, Head Start programs had the highest EBP met percentage scores (64.38%, 64.80%, 56.95%), followed by FCCH programs (50.93%, 49.68%, 48.50%), and center-based programs (37.01%, 36.65%, 37.18%). The findings showed a significant difference between program type (p<0.001). Specifically, center-based programs had significantly lower scores (36.9, 95% CI = 34.1, 39.8) than both Head Start (62.0, 95% CI = 57.7, 66.3; <0.0001) and FCCH programs (49.7, 95% CI = 46.7, 52.7; <0.0001). However, there were no statistically significant differences observed among programs based on the SAH order period (period, p = 0.178; interaction between program type and SAH order period, p = 0.293). Download figure Open in new tab Fig 2. Oral health evidence-based met percentage scores across different early childhood education program types during three key periods of the covid-19 pandemic DISCUSSION This study assessed the implementation of ECE oral health evidence-based practices during three COVID-19 time periods (i.e., pre-SAH, during-SAH, and post-SAH). Our findings revealed that Head Start programs had the highest EBP total and EBP met percentage scores than FCCH and center-based programs. Head Start program administrators’ self-assessment results reveal that their programs were the most engaged in oral health evidence-based practice recommendations than the other two program types. Based on our findings, government issued SAH orders did not explain the difference in EBP scores observed across the three programs. The primary cause for the difference in EBP total and EBP met percentage scores among all three programs is unclear. Perhaps, funding structure, although complex, can help explain the differences in scores we found. Centers’ oral health practices can differ based on funding source, state-funded, non-state funded ( 10 ). Scheunemann et al. (2015) compared toothbrushing as a routine classroom activity and funding source in ECE programs across the state of Wisconsin. They found that state-funded ECE centers were over two times more likely to have this practice than non-state funded. However, non-state funded were five times more likely to have any oral health educational practice. Head Start programs are federally funded and comprehensive and offer multiple services to children 0 – 5 years old and their families at no cost. These services include early learning and development, health and wellness, family well-being, and family engagement. Under health and wellness, oral health practices are promoted ( 15 ). This integration of oral health practices support could help explain why Head Start programs, with primarily federal funding, scored significantly higher than and FCCH and center-based programs, which are primarily funded via families’ fees. Unlike Head Start programs, FCCH and center-based programs generally do not offer such comprehensive services and perhaps specifically focus on other areas of early care and development ( 16 , 17 ). Therefore, these programs may view oral health practices as primarily the responsibility of families and focus their efforts on other priorities (e.g., child education, administrative duties, nutritional services) that align more closely with their organizational scope or resources ( 18 ). Some ECE staff have noted lack of time, educational health training, and administrative support and increased workload as barriers to implementing toothbrushing programs in ECE settings ( 18 ). Oral health practices should be prioritized by both ECE providers and families, as recommended by the American Academy of Pediatric Dentistry, to reduce the risk of ECC in young children. ECE may provide the only opportunity for some children to receive oral health care education. However, ECE programs are faced with different barriers that can impede their ability to provide adequate and quality oral health education and to children in their care. In a study by Bhoopathi, Joshi ( 19 ), ECE center directors reported funding issues and lack of training as the main self- perceived barriers to implementing oral health promotion practices in their center. Surprisingly, time, infection control, and lack of space were less common and Joufi, Claiborne ( 20 ) found time to also be the least reported anticipated barrier in implementing oral health promotion practices. Lack of training was also identified as a barrier by ECE teacher in a systematic review by Joufi, Claiborne ( 20 ) and a study of ECE directors by Joshi, Ocanto ( 21 ). In addition, teachers cited inadequate resources and examples as barriers to performing oral health activities with children ( 21 ). However, ECE staff members found an oral health training program effective in improving the oral health of children in their centers ( 20 ). Therefore, FCCH and center-based programs administrators, oral health leaders, and health departments who support ECE programs could focus on implementing oral health education training for program staff and provide the needed resources. To our knowledge, this study is the first to look at how three types of ECE programs in the US implemented oral health evidence-based practices during three COVID-19 time periods. However, like most studies, it is subject to at least two limitations. First, reporting bias and social desirability bias, the data shared here is from self-assessments completed by ECE administrators. Second, this is cross-sectional study and therefore any causal link between the program type and the EBP total and EBP met scores cannot be assessed. Despite these limitations, this study adds to the literature and provides information on the implementation of oral health evidence-based practices across three types of ECE programs in 23 states, Head Start, FCCH, and center-based. These findings can be used by ECE programs and policy makers to promote oral health education trainings for ECE teachers and administrators and provide relevant resources to encourage ECE staff and parents to consistently reinforce oral health practices with the children in their care. More broadly, research is also needed to better understand why center-based programs are not implementing more oral health evidence-based practices and determine what support is needed to help them increase their EBP total and EBP met scores. In conclusion, this study found that no child care program fully engaged in oral health evidence- based practices and Head Start programs had the highest level of engagement than family child care homes and center-based programs across three COVID-19 SAH periods. SAH orders did not explain the differences in scores we observed. ECE program policies should promote ECE administrators to prioritize oral health promotion practices to prevent early childhood caries among the children they serve. Data Availability All data files will be available from the The Carolina Digital Repository database. References 1. ↵ American Academy of Pediatric Dentistry . Policy on the Dental Home . The Reference Manual of Pediatric Dentistry . Chicago, IL : American Academy of Pediatric Dentistry ; 2023 . 2. ↵ National Institutes of Health . Oral health in America: advances and challenges . 2021 . 3. ↵ American Academy of Pediatric Dentistry . 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Use of paid child care health care consultants in early care and education settings: results of a national study comparing provision of health screening services among Head Start and non-Head Start centers . Journal of Pediatric Health Care . 2012 ; 26 ( 6 ): 427 – 35 . OpenUrl PubMed 18. ↵ Chandio N , Micheal S , Tadakmadla SK , Sohn W , Cartwright S , White R , et al. Barriers and enablers in the implementation and sustainability of toothbrushing programs in early childhood settings and primary schools: a systematic review . BMC Oral Health . 2022 ; 22 ( 1 ): 242 . OpenUrl PubMed 19. ↵ Bhoopathi V , Joshi A , Ocanto R , Jacobs RJ . Oral health promotion practices: a survey of Florida child care center directors . BMC Oral Health . 2018 ; 18 : 1 – 8 . OpenUrl PubMed 20. ↵ Joufi AI , Claiborne DM , Shuman D. Oral Health education and promotion activities by early head start programs in the United States: a systematic review . American Dental Hygienists’ Association . 2021 ; 95 ( 5 ): 14 – 21 . OpenUrl 21. ↵ Joshi A , Ocanto R , Jacobs RJ , Bhoopathi V. Florida child care center directors’ intention to implement oral health promotion practices in licensed child care centers . BMC Oral Health . 2016 ; 16 : 1 – 7 . OpenUrl PubMed View the discussion thread. Back to top Previous Next Posted April 10, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. 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