**IHS Head Start Oral Health Toolkit**

This toolkit is intended as a companion document to "Oral Health for
Head Start Children: Best Practices." While the Best Practices document
focuses on prevention and early intervention, the Toolkit contains
practical ideas and resources to assist Head Start programs 1) meet
their performance standards in the area of oral health, and 2) plan and
implement interventions to promote oral health for Head Start children
and their families.

American Indian and Alaska Native (AI/AN) children experience dental
caries at a higher rate than the general U.S. population. In order to
prevent dental caries in the primary teeth, we must intervene before the
first cavity develops, working with both mothers and infants. As
children enter Head Start, we want to prevent future decay in the
erupting permanent teeth.

Severe Early Childhood Cavities (ECC) causes pain and infection. Some
children learn to live with this pain day in and day out. ECC results in
increased missed school days and an inability to concentrate at school.
Pain also affects a child's sleep and nutrition, resulting in poor
overall health and well being. ECC can even result in poor self-esteem
and a reluctance to smile. The primary teeth are important for eating,
holding space for the permanent teeth, talking, and smiling.

Dental Caries is a preventable, infectious, transmissible disease caused
by mutans streptococci, lactobacilli, and other acid-producing bacteria.
The bacteria that cause tooth decay are fueled by sweet foods and drinks
and other fermentable carbohydrates like white crackers.

Traditional dental treatment alone does not stop these bacteria.
Treatment of Head Start children must be accompanied by use of topical
fluorides, antimicrobials, and other interventions to prevent future
dental decay in the permanent teeth.

![](media/image1.png){width="4.416666666666667in"
height="0.20416666666666666in"}

No child can be truly healthy

if he or she has poor oral health.

![](media/image1.png){width="4.416666666666667in"
height="0.20416666666666666in"}

***Indian Health Service and Head Start do not endorse any of the
products listed in the Tool Kit. Products are merely mentioned to
provide examples of tools to support oral health, and the products
listed represent only a sample of possible products that can be used to
support oral health in Head Start programs.***

**Steps to Getting Started**

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**Step 1: Written Health Plan**

**Step 2: Access to Dental Home**

**Step 3: Dental Assessments**

**Step 4: Dental Treatment**

**Step 5: Topical Fluoride Programs Implemented**

**Step 6: Dental Emergency Plan**

**Step 7: Integration of Nutrition & Dental Health Services**

**Step 8: Dental Education for children, parents, and staff**

**Step 9: Family Partnerships**

**Step 10: Health Advisory Committee**

**Step 11: Primary Prevention**

**And don't forget to document, document, document!**

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height="0.25555555555555554in"}

**Step 1: Written Health Plan**

Oral health should be an integral part of the written health plan, as
well as overall performance plan of your grant. It should include the
"who, what, when, and where" for arranging dental exams and treatment
for any children determined not to be up to date for these services. The
plan should also address parent consent and parent involvement at every
stage.

If you are establishing a new program, or periodically reviewing your
health plan as part of an assessment process, be sure to look at
examples of written health plans from other programs to provide
direction. Review the health plan yearly and change it to reflect your
own needs and resources.

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**Step 2: Access to Dental Home**

A dental home is a comprehensive, continuously accessible, and
affordable source of oral health care under the supervision of a
dentist. This can generally be arranged through your local Indian Health
Service or Tribal Dental Clinic, but those programs without these
resources will need to work with private dental health professionals.

Programs need to put a system in place to track dental services, from
the initial oral health determination through dental treatment
completion for each child. This allows the health coordinator and other
staff to participate in working with the family to assure that each
child's dental needs are met. These tracking devices also alert the
Health Coordinator when a child's dental care is not getting done so
that the Head Start program can intervene on the child's behalf.

Every child should be assessed for Medicaid eligibility. Even if the
child is eligible for IHS/Tribal dental care, it is important to enroll
each child with Medicaid so that the dental provider can collect state
funding to support dental services.

[Tracking Systems]{.underline}

There are various ways to track dental exams and treatment. Some
programs have developed excel spreadsheets for tracking while others use
computer-based tracking systems like ChildPlus. For a list of software
vendors that have customized their software to interact with the Head
Start National Reporting System, see the following website.

<https://www.hsnrs.net/dataimport.jsp>

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height="0.25555555555555554in"}

**Step 3: Oral Health Determination**

Every child should receive a determination as to whether he or she is up
to date on a schedule of age appropriate dental care from a health
professional within 90 days of enrollment. These health professionals
are staff or consultants who have training and experience in public
health, nursing, health education, maternal and child health, or health
administration. In AI/AN communities, it is up to the Head Start staff,
in coordination with the IHS/Tribal dental staff, to determine how to
most efficiently and effectively provide any needed dental care. While
some programs provide diagnostic and preventive care at the Head Start
centers, others prefer to bring the children to the dental clinic,
individually or in groups.

Consent for routine dental care and topical fluoride should be part of
the enrollment process. It is important that the results of any dental
screenings or exams are communicated in writing to the parents. A
standard form indicating whether or not the child needs treatment should
be provided to each family.

[Oral Health Determination Letter]{.underline}

This is a letter that can be sent home to guardians after an oral health
determination at the Head Start center.

![](media/image3.png){width="4.166666666666667in"
height="0.25555555555555554in"}

**Step 4: Dental Treatment**

If the child needs dental treatment, Head Start must assist parents in
making the necessary arrangements for dental treatment. This includes
but is not limited to providing education to parents, identifying
dentists, providing or arranging for transportation to the dentist, and
providing or arranging for child care services. In instances where
parents are unable to accompany their child to the dentist, Head Start
programs with written parental consent can either transport the child to
the dentist or have the dentist come to the center to provide services
to the child. Whether parents need to be present during dental treatment
is a local decision made in coordination between Head Start and the
IHS/Tribal dental program. Parents should, however, accompany their
child to dental appointments that involve extractions or other complex
dental treatment. If the Head Start staff is transporting children to
the dental clinic during the school day, it is important that parents
have signed the treatment plan and that they receive written information
about the dental treatment provided after each appointment.

[Dental Treatment Letter]{.underline}

This is a letter that can be sent home to the guardians to remind them
to get their child's dental work completed.

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height="0.25555555555555554in"}

**Step 5: Topical Fluoride Programs Implemented**

> Fluoride prevents cavities by making teeth stronger. Fluoride can even
> stop cavities when they are still tiny. There are several ways to
> provide fluoride including water fluoridation, systemic supplements
> (fluoride drops or tablets), fluoride toothpaste, and fluoride
> varnish. The amount of fluoride a child will benefit from depends on
> their dental caries risk. Since most AI/AN children are at high risk
> for dental caries, they will benefit from a combination of water
> fluoridation, fluoride toothpaste, and topical fluoride varnish
> treatments.

[Daily brushing with fluoride toothpaste]{.underline}.

All AI/AN children will benefit from daily brushing with a small smear
of fluoride toothpaste. For detailed instructions on cleaning the mouths
and teeth of infants and children in Head Start, see the following link:

[http://eclkc.ohs.acf.hhs.gov/hslc/Program%20Design%20and%20Management/Head%20Start%20Requirements/PIs/2006/resour_pri_00109_122006.html](http://eclkc.ohs.acf.hhs.gov/hslc/Program Design and Management/Head Start Requirements/PIs/2006/resour_pri_00109_122006.html)

![](media/image4.jpeg){width="1.8333333333333333in"
height="1.2180555555555554in"}

The recommended amount of toothpaste is a small smear. This is easy to
do if you apply the toothpaste across the width of the brush instead of
the length of the brush.

[Toothbrushing songs]{.underline}

Toothbrushing can become a group activity by having the children sing a
song before or during brushing.

Minnesota Dental Association has posted simple songs that the children
can sing while brushing. You can find the songs at the following
website.

<http://www.mndental.org/classroom/preschool/>

There is also a toothbrushing song included in the Bright Smiles, Bright
Futures Head Start curriculum by Colgate at the following website.

<http://www.colgate.com/app/BrightSmilesBrightFutures/US/EN/HomePage.cvsp>

[Toothbrushes and Toothbrush Racks]{.underline}

Be sure to purchase soft child-size toothbrushes. Your local IHS or
Tribal Dental Program may provide toothbrushes and fluoride toothpaste.
Check with them first. If you need to purchase these items, you can buy
any ADA approved fluoride toothpaste from local stores, but it will
probably be cheaper to order the toothbrushes from the websites listed
below. Toothbrush storage racks should provide for each toothbrush to be
stored and dried without touching the other brushes.

![](media/image5.jpeg){width="1.4680555555555554in" height="1.75in"}

[Dental Puppets]{.underline}

These are plush animals with large teeth that can be brushed. Dental
puppets are helpful to demonstrate brushing and also as a distraction
during the dental assessments.

[Baby Tenders]{.underline}

These are soft covers that are put on the caregiver's finger and then
the caregiver wipes the baby's teeth. A clean guaze or cloth can also be
used to clean an infant's teeth and gums.

There are many sources for the products listed above if you search the
internet. We have listed four here for your convenience.

![](media/image6.jpeg){width="1.75in"
height="1.4479166666666667in"}Practicon:
[www.practicon.com](http://www.practicon.com/)

SmileMakers: [www.smilemakers.com](http://www.smilemakers.com/)

Plak Smacker: [www.plaksmacker.com](http://www.plaksmacker.com/)

Paragon International:
[www.teachingaid.com](http://www.teachingaid.com/)

[Fluoride Varnish]{.underline}.

Since most AI/AN children are at high risk for future dental caries,
they will benefit from topical fluoride varnish treatments 2-4 times a
year. Fluoride varnish is a safe, effective method to provide topical
fluoride treatments to infants and toddlers. This can be coordinated
with your local dental program. Often local dental staff will come to
the Head Start center to provide fluoride varnish treatments, and they
may even provide the necessary supplies. Be sure to include consent
forms for topical fluoride treatments as part of the enrollment package.

[Fluoride Permission Form]{.underline}

This is a permission slip that you can modify for your own use for
fluoride varnish at Head Start centers.

[Fluoride Varnish for Children]{.underline}

[Paint to Prevent]{.underline}

[Fluoride Varnish for Your Baby's Teeth]{.underline}

These flyers and pamphlets are good education materials on fluoride
varnish, designed specifically for AI/AN families. You can download and
print these materials at:

<http://www.doh.ihs.gov/HPDP/index.cfm?fuseaction=resources.publications>

[Fluoride Varnish (Be sure to order the individual dose with applicator
included)]{.underline}

CavityShield: Omni Oral Pharmaceuticals, 1-800-445-3386

Duraflor: Medicom, 1-800-361-2862

![](media/image7.jpeg){width="1.6666666666666667in"
height="1.3388888888888888in"}

Duraphat: Colgate-Palmolive, 1-800-372-4346

**Handling and Storage of Toothbrushes in AIPB Head Start Programs**

(Indian Health Service Dental Program, and the Head Start IHS Program)

Tooth brushing with fluoridated toothpaste decreases dental decay rates.
Tooth brushing also helps to establish lifelong healthy habits to
maintain good oral health. These important benefits justify the
continued support for classroom tooth brushing programs. The proper
handling and storage of toothbrushes in Head Start programs is necessary
both to meet infection control standards and to satisfy the Head Start
Performance Standards.

Toothbrushes can become contaminated, and transmit germs or bacteria.
Common sense and proper hygiene practices should be the primary
considerations in the use and care of toothbrushes. The following
guidelines are suggested:

-   Each child should have his own toothbrush, marked with his name. No
    sharing or borrowing of toothbrushes should be allowed.

-   A pea-sized amount of fluoridated toothpaste should be dispensed
    onto a piece of paper or the bottom of a paper cup, but not directly
    from tube to brush.

-   Following use, toothbrushes should be air dried and stored so they
    cannot contact each other. They should be protected from dirt and
    cross contamination (that is, protected from touching each other).

-   Individual toothbrush covers may be used, but are not necessary or
    recommended. If used, they should be labeled with the child's name
    and have multiple air holes to allow ventilation and drying.

-   If storage units that hold multiple toothbrushes are used, these
    containers should allow the brushes to air dry, and not be in
    contact with other brushes, and be protected from dirt. Storage
    containers should be cleaned once a week with mild soap and hot
    water. Toothbrushes should remain separated and not allowed to
    contact one another during this cleaning.

-   Toothbrushes should never be decontaminated. Do not use bleach or
    disinfectants on toothbrushes. If a toothbrush becomes contaminated
    through contact with another brush or use by another child, it
    should be thrown away and replaced with a new one. Toothbrushes
    should be replaced when the bristles are flattened or splayed.
    Depending on the wear, brushes should be replaced about every three
    to five months.

-   Tooth brushing should always be supervised to ensure that
    toothbrushes are not shared and that they are handled properly. When
    possible, an adult should brush with the children. In addition to
    serving as a role model, the adult can monitor the children with
    respect to these procedures and guidelines.

Revised: May, 2006

Dr. Patrick Blahut

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**Step 6: Dental Emergency Plan**

A dental emergency plan should be part of your written health plan. This
is the specific guideline for what to do in the event of a dental
emergency, especially procedures for contacting parents and
transportation of the child to the dental clinic. A dental emergency
poster should be posted in each classroom, with instruction for first
aid in dental emergencies.

[First Aid for Dental Emergencies]{.underline}

This poster was updated in Fall 2006 by the IHS Head Start Program and
can be downloaded and printed from the website.

[Websites for additional information on dental emergencies]{.underline}

American Academy of Pediatric Dentistry:
[www.aapd.org/publications/brochures/ecare.asp](http://www.aapd.org/publications/brochures/ecare.asp)

American Dental Association

[www.ada.org/public/manage/emergencies.asp](http://www.ada.org/public/manage/emergencies.asp)

Colgate Bright Smiles, Bright Futures website has a Dental Emergencies
Chart that can be downloaded and printed

<http://www.colgate.com/app/BrightSmilesBrightFutures/US/EN/HomePage.cvsp>

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height="0.25555555555555554in"}

**Step 7: Integration of Nutrition & Dental Health Services**

Nutrition and oral health are important because of the role that
fermentable carbohydrates play in the process of dental caries. It is
important to offer snacks that don't cause cavities and to encourage
milk and water as the preferred beverages. It is also important to work
with families to discourage soda pop. Pop does not belong in the diets
of babies and preschoolers and families can help by not having pop in
the home and insisting on milk at meals.

[Stop the Pop]{.underline}

[Snack List for Healthy Teeth]{.underline}

These flyers and pamphlets are good education materials, designed
specifically for AI/AN families. You can download and print these
materials at:

<http://www.doh.ihs.gov/HPDP/index.cfm?fuseaction=resources.publications>

![](media/image3.png){width="4.166666666666667in"
height="0.25555555555555554in"}

**Step 8: Dental Education for children, parents, and staff**

Oral health should be included in the health curriculum for Head Start
children with take-home materials or educational sessions for parents.
There are various oral health curriculums available to implement in the
classroom. Health education is most effective when the Head Start
teachers are provided the necessary information to implement classroom
activities. Research has shown that when teachers are trained to provide
health education, they will incorporate health in various meaningful
ways throughout the school year. This is much more effective than having
a dental health professional make a presentation once a year.

[Bright Smiles, Bright Futures]{.underline}

This oral health and early literacy program for Head Start and early
childhood programs includes materials for classroom education and take
home materials for families. The materials can all be downloaded from
the following website for free. You must, however, register on the
website with your email address and a password that you create.

<http://www.colgate.com/app/BrightSmilesBrightFutures/US/EN/HomePage.cvsp>

For a list of additional curricula recommended by the National Head
Start Oral Health Resource Center, see the following website.

<http://www.mchoralhealth.org/HeadStart/materials/>

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height="0.25555555555555554in"}

**Step 9: Family Partnerships**

Early Head Start grantees and other programs serving pregnant women are
required to assist pregnant women to gain access to dental exams,
education, and health promotion services as early in their pregnancies
as possible.

Refer to "Oral Health for Head Start Children: Best Practices" document
for strategies to improve the oral health of pregnant women and their
infants. These interventions require coordination with IHS/Tribal dental
programs, MCH programs, WIC, and Head Start.

The New York State Department of Health has developed a manual "Oral
Health Care During Pregnancy and Early Childhood: Practice Guidelines."

<http://www.health.state.ny.us/publications/0824.pdf>

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**Step 10: Health Advisory Committee**

As a best practice, the Head Start Health Advisory Committee should
include a dentist, dental hygienist, or dental assistant. It is
advisable to meet with the local dentist to extend an invitation to
participate in the Health Advisory Committee and if he/she is unable to
participate, ask for another representative from the dental program.

If you are going to keep the attention of busy health providers, it is
important that your meetings be well organized and brief. If you can
hold your meeting during the lunch hour and provide food, that is even
better. Be sure to distribute an agenda before the meeting.

"Weaving Connections" is a multimedia set of training materials for Head
Start programs that focuses on the Health Services Advisory Committee.
The Weaving Connections kit provides information and resources to help
Head Start staff, parents, and HSAC members run an effective HSAC, and
improve outcomes for children and families. For more information, check
out the website below.

<http://www.acf.hhs.gov/programs/hsb/connections/index.htm>

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**Step 11: Primary Prevention**

If we are ever going to change the prevalence of dental caries among
AI/AN children, we must be involved in dental disease prevention.
Education, daily use of fluoride toothpaste, and the provision of
topical fluoride treatments is a start. Some programs, however, would
like to do more to reduce the bacteria that cause cavities.

Primary Teeth: Early Childhood Caries (ECC) is the disease that causes
cavities in the primary, or baby teeth. In order to prevent this
disease, we must work with pregnant women and infants. By two years of
age, many AI/AN children already have decay in their baby teeth.
Interventions include xylitol and chlorhexidine regimens for women soon
after birth to reduce the cavity-causing bacteria in the mother which
will lower the amount and strength of the bacteria passed on to the
child. IHS and Tribal dental programs want to see babies soon after the
first tooth erupts and no later than one year of age to assess the
infant's risk for dental caries and also to begin education and topical
fluoride treatments.

Permanent Teeth: Through the implementation of xylitol programs in Head
Start programs, we can reduce the number and strength of the bacteria in
a preschooler's mouth which will reduce cavities in the future permanent
teeth.

> [Xylitol]{.underline}
>
> Xylitol is a natural sweetener, derived from plants, that is found in
> certain gum, mints, and other foods. It has the ability to actually
> kill the bacteria that cause cavities. The safety of xylitol has been
> extensively studied both in the US and internationally.
>
> School-based xylitol programs have been proven effective at reducing
> dental caries. Ideally, the children need to be involved for at least
> one full school year and should receive the therapeutic dose at least
> five days a week. Since xylitol actually alters the cavity-causing
> bacteria, the children will benefit from this intervention for years
> to come.

Through Head Start, consider implementing a xylitol program for 3-5 year
olds. Each child should receive at least 5 grams of xylitol daily during
the school year. This is best accomplished by chewing xylitol gum or
specially-ordered xylitol candy 3 times a day. It is usually given after
breakfast, after lunch, and in the late afternoon either during circle
time or on the way out the door.

Work with a local dentist to choose a xylitol product and order enough
for each child to receive a therapeutic dose for one school year. You
are looking for a product that lists xylitol as the first ingredient.
Store the gum/mints under lock and key. Although not dangerous,
ingestion of a large amount may cause diarrhea in some children.

Refer to "Oral Health for Head Start Children: Best Practices" for more
information about preventing dental caries.

[Early Childhood Cavities: A Crisis Among Native American
Children]{.underline}

[Baby Teeth are Important]{.underline}

[Pregnancy and Dental Health]{.underline}

[Xylitol]{.underline}

[Control with Xylitol the Natural Way]{.underline}

These flyers and pamphlets are good education materials on fluoride
varnish, designed specifically for AI/AN families. There are a wealth of
education materials that can be downloaded and printed from the Indian
Health Service website listed below.

Click on "Resources" on the left hand side, and then click on "Resource
Guide".

<http://www.doh.ihs.gov/HPDP/>

**Every community should work with pregnant women**

**and infants to prevent ECC. It is worth the effort.**

**Just imagine if it really works. and the children entering**

**Head Start in the future are mostly cavity-free.**

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height="0.25555555555555554in"}

**Don't forget to document, document, document!**

It is important to meet the performance standards, but when it becomes
impossible, it is important to document why. Most of the performance
standards relating to oral health are achievable through the
organization and hard work of the Head Start staff. Some standards, like
completing dental treatment, are often out of your control. In these
instances, it becomes increasingly important that you document all
attempts at compliance

The National Head Start Oral Health Resource Center has a large
collection of online resources on oral health. Be sure to check out this
valuable website.

<http://www.mchoralhealth.org/HeadStart/materials/>

You might also want to register to receive the National Head Start "Oral
Health Alert", a free monthly electronic newsletter that provides timely
information about Head Start oral health-related national campaigns and
initiatives, Web sites, data releases, materials, and journal articles.
To subscribe, go to <http://www.mchoralhealth.org/alert/index.html>

**List of Key Performance Standards Related to Oral Health**

For a complete list and wording of the Head Start Performance Standards
see:

<http://www.access.gpo.gov/nara/cfr/waisidx_05/45cfrv4_05.html#1301>

**1304.20 Written Health Plan**

> **Access to Dental Home**
>
> **Dental Assessments**
>
> **Dental Treatment**
>
> **Topical Fluoride Programs Implemented**
>
> **Primary Prevention**

**1304.21 Dental Education for children, parents, and staff**

**1304.22 Dental Emergency Plan**

**1304.23 Integration of Nutrition & Dental Health Services**

**1304.40 Family Partnerships**

**1304.41 Health Advisory Committee**