**Oral Health for Head Start Children: Best Practices**

January 31, 2007

"Oral Health for Head Start Children: Best Practices" provides
evidence-based approaches and interventions to improve the oral health
of Head Start children and their families. The Best Practices are
divided into three key points of intervention; pregnancy, birth through
two years, and two years through five years of age. The prevention of
Early Childhood Caries requires an approach that involves pregnant women
and infants. Interventions during the preschool years are primarily
targeted to the prevention of dental caries in the permanent teeth.

We expect this document to be helpful to Head Start administration and
staff and all of the medical, dental, and community health staff who
will need to work together to effectively improve the future oral health
of American Indian and Alaska Native children. We hope to spread our
vision of a future where American Indian and Alaska Native children no
longer suffer from Early Childhood Caries at the alarming rates that
they do currently.

We will continually update this document and you will be able to access
those updates on the IHS Head Start Program website:

[www.ihs.gov/nonmedicalprograms/headstart/](http://www.ihs.gov/nonmedicalprograms/headstart/)

You can also find current information and bulletins on oral health as it
relates to Head Start at the Head Start Bureau Learning Center at the
following website:

[[http://www.eclkc.ohs.acf.hhs.gov/hslc]{.underline}](http://www.eclkc.ohs.acf.hhs.gov/hslc)

IHS Head Start Program

Albuquerque, NM

**Just The Facts**

Early Childhood Caries (ECC) is the single most common chronic disease
of childhood, occurring at least five times more frequently than asthma,
the second most common chronic disease of childhood.

American Indian and Alaska Native (AI/AN) children experience dental
caries at a higher rate than the general U.S. population. Data from
2,663 children ages 2-5 years documented that 79 percent had experienced
dental caries (filled or unfilled decay) and 68 percent had untreated
dental caries. Over 50 percent of the children ages 2-5 years had severe
Early Childhood Caries (ECC).\*

By [two years of age]{.underline}, only 30 percent of AI/AN children
surveyed were caries-free, supporting the fact that prevention
interventions must be implemented with pregnant women and infants. In
order to prevent dental caries in the primary teeth, we must intervene
before the first cavity develops, working with both mothers and infants.
For children in Head Start, we want to prevent future decay in the
erupting permanent teeth.

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. Over time, the
enamel breaks down, resulting first in a chalky white spot that then
progresses to a cavity.

Severe ECC causes pain and infection. ECC can also 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.

Severe ECC can cost from \$2,000-\$5,000 or more per child to treat.
Some of these children need to be hospitalized, and treatment may need
to be completed under general anesthesia. ECC places a huge financial
burden on insurance, Medicaid, Indian Health Service, Tribal programs,
and families least able to afford treatment.

Dental treatment does not remove the disease-causing bacteria. Even
after treatment, the disease rages on for high-risk children.

![](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"}

**Introduction**

Early Childhood Caries (ECC) is a term used to describe tooth decay,
including filled or extracted teeth due to decay, in the primary teeth
(baby teeth). Other names for this disease are Baby Bottle Tooth Decay
(BBTD), nursing mouth, and bottle rot. Severe ECC is characterized by a
distinctive pattern of tooth decay in infants and young children, often
beginning on the maxillary anterior teeth and rapidly progressing to the
other primary teeth as they erupt.

ECC is a preventable, infectious, transmissible disease caused by mutans
streptococci, lactobacilli, and other acid-producing bacteria. While the
transmission is primarily vertical between mothers or other primary
caregivers and infants, studies have also demonstrated horizontal
transmission from infants to infants, as well as from older children to
infants. We now know that the organisms that cause dental caries can
begin to colonize in the mouth of an infant even before the eruption of
teeth. The bacteria that cause tooth decay produce acids from
carbohydrates. The bacteria are fueled by sweet foods and drinks and
other fermentable carbohydrates. Over time, the enamel demineralizes,
resulting first in a chalky white spot that then progresses to a cavity.
It is important to rethink the way we "treat" dental caries.
Traditionally, we would wait until a child had a cavity and "treat" the
cavity with a filling. In order to prevent ECC, we must intervene before
the first cavity develops, working with both mothers and infants.

**Problem Statement**

American Indian and Alaska Native (AI/AN) children experience dental
caries at a higher rate than the general U.S. population. Data from
2,663 children ages 2-5 years documented that 79 percent had experienced
dental caries (filled or unfilled decay) and 68 percent had untreated
dental caries.\* Over 50 percent of the children ages 2-5 years had
severe Early Childhood Caries, constituted by decay on a maxillary
incisor or six or more decayed teeth. At two years of age, only 30
percent of the AI/AN children were caries-free, supporting the fact that
prevention interventions must be implemented with pregnant women and
infants.

Severe ECC causes pain and infection. Many of these 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 also 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. We can no longer ignore this
infection until a child is 3-4 years old, any more than we would ignore
any other infection that a child might have.

\* *The 1999 Oral Health Survey of American Indian and Alaska Native
Dental Patients: Findings, Regional Differences and National
Comparisons.* DHHS, IHS Division of Oral Health.

![](media/image1.png){width="4.0625in" height="0.1875in"}

+----------------+-----------------------------------------------------+
| **Rec          | **Oral Health: Best Practices during Perinatal      |
| ommendations** | Period**                                            |
+================+=====================================================+
| **Collaborate  | >                                                   |
| with the       |  ![](media/image2.png){width="0.7409722222222223in" |
| medical,       | > height="1.3680555555555556in"}***Why?***          |
| community      | >                                                   |
| health, and    | > Pregnant women should get their teeth cleaned and |
| dental         | > checked early in their pregnancy. Gum disease has |
| providers to   | > been linked to premature low birth-weight babies. |
| assure that    | >                                                   |
| all pregnant   | > The caries risk assessment gives you the          |
| women visit    | > opportunity to assess whether the baby will be at |
| the dental     | > high risk for future dental caries and also       |
| clinic during  | > provides an opportunity to educate the mother     |
| the early      | > about ways to prevent ECC.                        |
| months of      | >                                                   |
| pregnancy.**   | > Modification of the mother's dental flora during  |
|                | > the period from birth until the child is two      |
| **Educate the  | > years of age can lower the bacteria transmitted   |
| mother about   | > to the baby and positively affect the child's     |
| the            | > future dental caries risk. A 6-year study in      |
| tr             | > Finland showed that mothers who chewed xylitol    |
| ansmissibility | > gum during the first two years of their           |
| of dental      | > children's lives led to lower levels of caries in |
| caries and     | > their children.                                   |
| ways to        |                                                     |
| prevent ECC.** | ***Supporting Articles***                           |
|                |                                                     |
| **Provide      | > Xiong X, et al Periodontal disease and adverse    |
| nutrition      | > pregnancy outcomes: a systematic review,          |
| counseling to  | > International J of Obstetrics and Gynecology, Oct |
| reinforce the  | > 2005.                                             |
| importance of  |                                                     |
| a healthy diet | Kanellis MJ. Caries risk assessment and prevention: |
| during the     | strategies for Head Start, Early Head Start and     |
| perinatal      | WIC. J Public Health Dent. 60(3):210-17, discussion |
| period.**      | 218-20, 2000.                                       |
|                |                                                     |
| **Provide      | Kanellis M, et al. S mutans suppression in          |
| education and  | preschool children using 1% chlorhexidine gel.      |
| support to     | Abstract at                                         |
| promote        | <http://confex.c                                    |
| br             | om/iadr/2004Hawaii/techprogram/abstract_39586.htm>. |
| eastfeeding.** |                                                     |
|                | Scheer M and Phipps K. Compliance with              |
| **Recommend    | chlorhexidine and xylitol among high risk mothers.  |
| that pregnant  | Abstract. J Public Health Dent. 63(Suppl 1):S38,    |
| women stop     | 2003.                                               |
| using          |                                                     |
| tobacco.**     | Soderling E, Isokangas P, Pienihakkinen K, et al.   |
|                | Influence of maternal xylitol consumption on        |
| **The dental   | mother-child transmission of mutans streptococci:   |
| staff can      | 6-year follow-up. Caries Res. 35(3):173-77, 2001.   |
| provide an     |                                                     |
| oral exam,     | > [The following are all from the Journal of the    |
| periodontal    | > California Dental Association, February 2003 and  |
| disease        | > March 2003:]{.underline}                          |
| screening,     | >                                                   |
| prophylaxis,   | > Lynch, H. and Milgrom, P. Xylitol and Dental      |
| r              | > Caries: An Overview for Clinicians.               |
| ecommendations | >                                                   |
| for completing | > Anderson, MH. A Review of the Efficacy of the     |
| any needed     | > Chlorhexidine on Dental Caries and the Caries     |
| dental         | > Infection                                         |
| treatment,     | >                                                   |
| caries         | > Berkowitz, RM Acquisition and transmission of     |
| control, and   | > Mutans Streptococci.                              |
| appropriate    | >                                                   |
| recall.**      | > Featherstone JDB et al. Caries Management by Risk |
|                | > Assessment: Consensus Statement, April 2002.      |
| **Assess the   | >                                                   |
| mother's       | > ![](media/image2.png){width="0.3375in"            |
| caries risk    | > height="0.6229166666666667in"}                    |
| and prescribe  | >                                                   |
| a              | > ***How?***                                        |
| nti-bacterials |                                                     |
| like           | Collaborate between the medical, community health,  |
| chlorhexidine  | and dental providers to assure that all pregnant    |
| or xylitol for | women visit the dental clinic during the early      |
| high-risk      | months of pregnancy. Head Start, WIC, and other     |
| mothers during | tribal health programs that serve pregnant women    |
| the perinatal  | can also participate as partners to encourage       |
| period.**      | pregnant women to visit the dentist. The following  |
|                | list of recommendations for education should be     |
| **Note:        | reinforced by the various medical providers, dental |
| Education      | staff, community health workers, and other partners |
| alone is not a | as identified in each community.                    |
| best practice. |                                                     |
| Effective      | -   Refer all pregnant women to the dental clinic   |
| health         |     during the early months of pregnancy.           |
| education      |                                                     |
| includes       | -   Educate the mother about the transmissibility   |
| motivational   |     of dental caries and ways to prevent ECC.       |
| interviewing,  |                                                     |
| d              | -   Reinforce the importance of a healthy diet and  |
| emonstrations, |     limited snacking on pop, sweets, and starchy    |
| and            |     snacks like potato chips and white crackers     |
| reinforcement. |     because they cause cavities. It is also         |
| Motivational   |     important to get plenty of calcium for baby's   |
| interviewing   |     teeth and bones. It is found in milk, cheese,   |
| is a form of   |     dried beans, and leafy green vegetables.        |
| counseling     |                                                     |
| that is client | -   Support breastfeeding at every opportunity.     |
| centered,      |                                                     |
| involving more | -   Educate the mother about gum disease as it      |
| listening than |     relates to the health of her baby. Recommend    |
| talking and    |     and demonstrate daily brushing with fluoride    |
| encouraging    |     toothpaste and flossing or other methods to     |
| clients to     |     clean in between the teeth and gums.            |
| come up with   |                                                     |
| their own      | -   Recommend that pregnant women stop using        |
| solutions to   |     tobacco. It is unhealthy for both baby and      |
| health         |     mother and it also is a contributing factor in  |
| behavior       |     gum disease.                                    |
| change.**      |                                                     |
|                | The dental staff can provide an oral exam,          |
| **[Glossary]   | periodontal disease screening, prophylaxis,         |
| {.underline}** | recommendations for completing any needed dental    |
|                | treatment, caries control, and appropriate recall.  |
| **ECC**: Early |                                                     |
| Childhood      | ![](media/image2.png){width="0.3375in"              |
| Caries,        | height="0.6229166666666667in"}                      |
| previously     |                                                     |
| called Baby    | The dental staff can assess the woman's caries risk |
| Bottle Tooth   | either by existing disease or by providing a strep  |
| Decay. This    | mutan test and work with the mother to establish an |
| term refers to | effective and appropriate caries control program.   |
| dental decay   |                                                     |
| on the         | Anti-bacterials can be prescribed during the period |
| primary, or    | from birth until the child is two years,            |
| baby teeth.    | specifically chlorhexidine and xylitol.             |
|                | Chlorhexidine therapy would consist of 0.12 percent |
| **Primary      | chlorhexidine gluconate, used as a prescription     |
| Teeth**: Baby  | mouthrinse, 10 ml daily for one week per month or   |
| Teeth          | for 2-3 weeks straight and repeated every 2-3       |
|                | months, for approximately a year. Xylitol therapy   |
| **Dental       | would consist of daily use of lozenges, mints, or   |
| Caries**: The  | gum, either over-the-counter brands or various      |
| disease        | sources ordered from dental suppliers and over the  |
| process that   | internet. The therapeutic dose is 5-10 grams per    |
| leads to       | day. For a therapeutic dose, xylitol must be listed |
| cavities, or   | as the first ingredient.                            |
| tooth decay.   |                                                     |
|                | The downside of current anti-bacterial therapy is   |
| **             | that it requires a high level of compliance on the  |
| Prophylaxis**: | part of the mother. There is no evidence that       |
| Procedures to  | xylitol or chlorhexidine regimens that are          |
| clean the      | sporadically followed have any effect at all.       |
| teeth of       | Therefore, effective interventions will require     |
| plaque,        | that health providers, WIC staff, community health  |
| calculus, and  | workers, and dental providers work together to      |
| stain.         | reinforce compliance.                               |
|                |                                                     |
| **Perinatal**: | The New York State Department of Health has         |
| As used in     | developed a manual "Oral Health Care During         |
| this document, | Pregnancy and Early Childhood: Practice Guidelines" |
| it refers to   | It is located at                                    |
| the period of  | <h                                                  |
| time during    | ttp://www.health.state.ny.us/publications/0824.pdf> |
| pregnancy and  |                                                     |
| one year after | ![](media/image1.png){width="4.0625in"              |
| birth          | height="0.1875in"}                                  |
+----------------+-----------------------------------------------------+

+----------------+-----------------------------------------------------+
| **Rec          | **Oral Health: Best Practices from Birth through    |
| ommendations** | Two Years**                                         |
+================+=====================================================+
| **Provide an   | >                                                   |
| oral health    |  ![](media/image3.png){width="0.8673611111111111in" |
| assessment     | > height="1.2493055555555554in"}***Why?***          |
| soon after the | >                                                   |
| first tooth    | > By two years of age, most AI/AN children already  |
| erupts or by   | > have decay in their baby teeth. To prevent this   |
| 12 months of   | > disease, we must intervene soon after the first   |
| age.**         | > tooth erupts. An infant oral health assessment is |
|                | > recommended by the American Dental Association,   |
| **Provide      | > American Association of Pediatric Dentists,       |
| topical        | > American Public Health Association, American      |
| fluoride       | > Association of Public Health Dentistry, and the   |
| varnish        | > American Academy of Pediatrics.                   |
| treatments 4   | >                                                   |
| or more times  | > Fluoride works by inhibiting demineralization,    |
| during the     | > enhancing remineralization, and inhibiting plaque |
| period from    | > bacteria. Fluoride varnish is a safe, effective   |
| 9-24 months of | > method to provide topical fluoride treatments to  |
| age.**         | > infants and toddlers.                             |
|                | >                                                   |
| **Educate      | > ***Supporting Articles***                         |
| families about | >                                                   |
| the importance | > Holve S. Fluoride Varnish Applied at Well Child   |
| of never       | > Care Visits Can Reduce Early Childhood Caries.    |
| putting baby   | > IHS Primary Care Provider, October 2006.          |
| in bed with a  | > <http://www.ihs.gov/PublicIn                      |
| bottle, using  | fo/Publications/HealthProvider/issues/PROV1006.pdf> |
| a cup by 6     | >                                                   |
| months, and    | > [The following articles are all from the Journal  |
| weaning off    | > of the California Dental Association, February    |
| the bottle at  | > 2003 and March 2003:]{.underline}                 |
| 12-14 months   | >                                                   |
| of age.**      | > Featherstone JDB et cal. Caries Management by     |
|                | > Risk Assessment: Consensus Statement, April 2002. |
| **Educate      | >                                                   |
| families about | > Featherstone, JDB, et al. The Caries Balance:     |
| the protective | > Contributing Factors and Early Detection.         |
| qualities of   | >                                                   |
| fluoride       | > Ramos-Gomex, FJ et al. Implementing an Infant     |
| Ideally, every | > Oral Care Program.                                |
| child should   | >                                                   |
| be drinking    | > Donly, KJ Fluoride Varnishes.                     |
| fluoridated    | >                                                   |
| water and have | > ***Supporting Materials***                        |
| their teeth    | >                                                   |
| cleaned daily  | > Note: Many programs have already developed        |
| with a small   | > training materials to teach medical, dental, and  |
| dab of         | > community health workers to provide an oral       |
| fluoride       | > health assessment and fluoride varnish            |
| toothpaste.**  | > treatments. The resources listed below are a      |
|                | > combination of online courses, manuals, and other |
| **Educate      | > materials to support these trainings. The IHS     |
| families to    | > Provider article by Holve (see weblink above)     |
| lift the lip   | > outlines an IHS model for intervention at         |
| and look for   | > well-child visits.                                |
| chalky white   | >                                                   |
| or brown       | > Phoenix College Online Course on ECC for Dental   |
| spots, telling | > and Medical Health Professionals                  |
| them that if   | >                                                   |
| they see any   | > [www.pc.maricopa.edu/dental/ecc/previe            |
| signs of       | w/](http://www.pc.maricopa.edu/dental/ecc/preview/) |
| dental decay,  | >                                                   |
| they should    | > The National Maternal & Child Oral Health         |
| see the        | > Resource Center: educational materials and        |
| dentist.**     | > program descriptions on many oral health topics.  |
|                | >                                                   |
| **Encourage    | > [ww                                               |
| healthy snacks | w.mchoralhealth.org](http://www.mchoralhealth.org/) |
| and limited    | >                                                   |
| exposure to    | >                                                   |
| sweets,        |  ![](media/image3.png){width="0.4027777777777778in" |
| refined        | > height="0.5805555555555556in"}First Smiles        |
| starches like  | > Project in California: education materials for    |
| chips and      | > medical team, dental team, early childhood        |
| crackers, and  | > education team, and parents                       |
| sweetened      | >                                                   |
| drinks.        | > <http://www.first5oralhealth.org/>                |
| Reinforce to   | >                                                   |
| families that  | > ABCD: University of Washington and Washington     |
| pop does not   | > State Department of Social and Health Services:   |
| belong in a    | > videotapes, posters, cups, and other materials    |
| preschooler's  | >                                                   |
| diet.**        | > [www.abcd-dental                                  |
|                | .org/res.html](http://www.abcd-dental.org/res.html) |
| **As part of   | >                                                   |
| the Early Head | > Open Wide: Oral Health Training for Non-Dental    |
| Start program  | > Health and Human Services Providers: PowerPoint   |
| requirements,  | > presentationas and other materials for training   |
| infants and    | > non-dental health professionals to provide infant |
| toddlers will  | > screening                                         |
| have their     | >                                                   |
| teeth cleaned  | > <http://oralh                                     |
| daily with a   | ealth.infostats.com/test/publications_reports.html> |
| small smear of | >                                                   |
| fluoride       | > American Academy of Pediatric Dentists "Caries    |
| toothpaste.**  | > Risk Asseessment Tool"                            |
|                | >                                                   |
| **Note:        | > <http://www.aapd.or                               |
| Education      | g/media/Policies_Guidelines/P_CariesRiskAssess.pdf> |
| alone is not a | >                                                   |
| best practice. | > ***How?***                                        |
| Effective      |                                                     |
| health         | Collaborate with medical, dental, community health, |
| education      | Head Start, daycare centers, WIC, and other tribal  |
| includes       | organizations who serve infants and their families. |
| motivational   | Train medical, dental, and other community health   |
| interviewing,  | workers to provide an oral health assessment and    |
| d              | fluoride varnish treatments for infants and young   |
| emonstrations, | children. (see above resources for specifics on     |
| and            | "how to")                                           |
| re             |                                                     |
| inforcement.** | Provide a fluoride varnish treatment during the     |
|                | first oral health assessment and aim to provide 4   |
| **Motivational | or more treatments during the period from 9-24      |
| interviewing   | months of age. Given the high prevalence of dental  |
| is a form of   | caries in AI/AN children, most children will be     |
| counseling     | classified at high risk and therefore, some         |
| that is client | programs may choose to follow a fluoride varnish    |
| centered,      | protocol for all infants and toddlers. Other        |
| involving more | programs may choose to assess individual risk and   |
| listening than | apply fluoride varnish only for children determined |
| talking and    | to be at high risk for dental caries. High risk is  |
| encouraging    | determined if any white or brown spot lesions are   |
| clients to     | observed, if the baby is on the bottle past one     |
| come up with   | year of age, or if any siblings had ECC. For a more |
| their own      | complex assessment of individual risk, refer to the |
| solutions to   | American Academy of Pediatric Dentists "Caries Risk |
| health         | Assessment Tool" referenced above.                  |
| behavior       |                                                     |
| change.**      | Refer to a dentist if chalky white spots, brown     |
|                | spots or other signs of dental decay are observed.  |
|                | Chalky white spot lesions can be remineralized with |
|                | fluoride varnish. If lesions have already           |
|                | progressed into the dentin, they can be treated     |
|                | with ART (Alternative Restorative Technique) where  |
|                | the decay is scooped out and a fluoride-releasing   |
|                | material is placed in the lesion. No anesthesia or  |
|                | drills are used in this technique. The dental       |
|                | program will recall the child as appropriate, based |
|                | on caries risk.                                     |
|                |                                                     |
|                | Note: While our overall goal is the prevention of   |
|                | ECC, early screening and the use of fluoride        |
|                | varnish and ART have the potential to manage ECC in |
|                | AI/AN children, avoiding expensive referrals to     |
|                | pediatric dentists and extensive treatment under    |
|                | general anesthesia.                                 |
|                |                                                     |
|                | ![](media/image3.png){width="0.4027777777777778in"  |
|                | height="0.5805555555555556in"}                      |
|                |                                                     |
|                | The following list of recommendations for education |
|                | should be reinforced by the various medical         |
|                | providers, dental staff, community health workers,  |
|                | Head Start, and other partners as identified in     |
|                | each community.                                     |
|                |                                                     |
|                | -   Teach families to lift the lip and look for     |
|                |     chalky white or brown spots, telling them that  |
|                |     if they see any signs of dental decay, they     |
|                |     should see the dentist.                         |
|                |                                                     |
|                | -   Educate families about the protective qualities |
|                |     of fluoride. Ideally, every child should be     |
|                |     drinking fluoridated water and have their teeth |
|                |     brushed daily with a small dab of fluoride      |
|                |     toothpaste                                      |
|                |                                                     |
|                | -   Educate and demonstrate to families, Early Head |
|                |     Start staff, and daycare staff how to clean     |
|                |     infants' and toddlers' mouths. For infants, a   |
|                |     clean wipe, gauze, or other infant cleaning     |
|                |     tool is used to wipe the gums and any erupting  |
|                |     teeth. Once a few teeth have erupted, a baby or |
|                |     child size toothbrush can be used to brush the  |
|                |     teeth.                                          |
|                |                                                     |
|                | -   Educate families about the importance of never  |
|                |     putting baby in bed with a bottle, using a cup  |
|                |     by 6 months, and weaning at 12-14 months of     |
|                |     age.                                            |
|                |                                                     |
|                | -   Encourage healthy snacks and limited exposure   |
|                |     to sweets, refined starches like chips and      |
|                |     crackers, and sweetened drinks. Reinforce to    |
|                |     families that pop does not belong in a          |
|                |     preschooler's diet.                             |
|                |                                                     |
|                | > ![](media/image1.png){width="4.0625in"            |
|                | > height="0.1875in"}                                |
+----------------+-----------------------------------------------------+

  ---------------------------------------------------------------------------
  **Recommendations**   **Oral Health: Best Practices from Three through Five
                        Years**
  --------------------- -----------------------------------------------------

  ---------------------------------------------------------------------------

+----------------+-----------------------------------------------------+
| **Provide a    | > ***Why?***                                        |
| yearly oral    | >                                                   |
| health         | > ![](media/image4.png){width="1.5in"               |
| determination  | > height="1.0in"}Most AI/AN children will either    |
| and assure     | > have ECC or not by this age. The focus now is on  |
| that every     | > stopping the caries process in children with ECC  |
| child has a    | > and preventing future caries in the permanent     |
| dental home.** | > teeth for all children. Any child with dental     |
|                | > decay or white spot lesions in his/her primary    |
| **Provide      | > teeth should be considered at high risk for       |
| topical        | > future dental caries.                             |
| fluoride       |                                                     |
| varnish        | Fluoride is effective as a protective factor        |
| treatments     | against dental caries. Scientific studies have      |
| every 3-4      | documented 15-30 percent reduction in caries with   |
| months for     | daily use of a fluoride toothpaste. Fluoride is     |
| children at    | added to about 90% of the toothpaste produced in    |
| high risk for  | the US, Canada and other developed countries.       |
| dental         | Topical fluoride (toothpaste, fluoride varnish) is  |
| caries.**      | absorbed directly into dental plaque and the outer  |
|                | layers of the tooth that are in the beginning       |
| **Collaborate  | stages of demineralizing. Fluoride can stop         |
| with families  | cavities from forming and can arrest the growth of  |
| and the dental | existing cavities.                                  |
| provider to    |                                                     |
| get any needed | Studies show that the more sugar children consume,  |
| dental         | the higher their threshold for sweetness. The       |
| treatment      | consumption of soft drinks, including carbonated    |
| completed.**   | beverages, fruit juices and sports drinks in the US |
|                | has increased 500% in the past 50 years and shows   |
| **Consider     | no sign of leveling off. Soda pop consumption       |
| dental         | begins early and increases as children age.         |
| sealants for   | Sugar-containing soft drinks can cause dental decay |
| the primary    | and the excess sugar can lead to obesity and type   |
| molars of any  | II diabetes in children. Some sodas have as much as |
| children who   | 13 teaspoons of sugar. High consumption of soft     |
| are at high    | drinks has also been shown to reduce consumption of |
| risk for       | milk, an important source of calcium for young      |
| dental         | children.                                           |
| caries.**      |                                                     |
|                | > Xylitol is a natural sugar that is found in       |
| **Educate      | > certain gums, mints, and other foods. Xylitol is  |
| families about | > found in many plants but is usually processed     |
| the protective | > from the birch tree. It has the ability to        |
| qualities of   | > actually kill the bacteria that cause cavities.   |
| fluoride.      | > The safety of xylitol has been extensively        |
| Ideally, every | > studied both in the US and internationally. The   |
| child should   | > only side effect noted in animal studies appears  |
| be drinking    | > to be mild diarrhea with ingestion of very large  |
| fluoridated    | > amounts.                                          |
| water and have | >                                                   |
| their teeth    | > School-based xylitol programs have been proven    |
| brushed daily  | > effective at reducing dental caries. Ideally, the |
| with a small   | > children need to be involved for at least one     |
| smear of       | > full school year and should receive the           |
| fluoride       | > therapeutic dose at least five days a week. Since |
| toothpaste.**  | > xylitol actually alters the cavity-causing        |
|                | > bacteria, the children will benefit from this     |
| **Encourage    | > intervention for years to come.                   |
| healthy snacks | >                                                   |
| and limited    | >                                                   |
| exposure to    |  ![](media/image4.png){width="0.6756944444444445in" |
| sweets,        | > height="0.45069444444444445in"}                   |
| refined        | >                                                   |
| starches like  | > ***Supporting Articles***                         |
| chips and      | >                                                   |
| crackers, and  | > Recommendations for Using Fluoride to Prevent and |
| sweetened      | > Control Dental Caries in the United States. MMWR, |
| drinks.        | > 50(RR-14):1-42, August 17, 2001.                  |
| Reinforce to   | >                                                   |
| families that  | > Weintraub JA. Fluoride varnish for caries         |
| pop does not   | > prevention: Comparisons with other preventive     |
| belong in a    | > agents and recommendations for a community-based  |
| preschooler's  | > protocol. Special Care in Dentistry. 23(5):180-6, |
| diet.**        | > 2003                                              |
|                |                                                     |
| **Through Head | Anderson M. Chlorhexidine and xylitol gum in caries |
| Start,         | prevention. Special Care in Dentistry. 23(5):173-6, |
| consider       | 2003.                                               |
| implementing a |                                                     |
| xylitol        | Autio JT and Courts FJ. Acceptance of the xylitol   |
| program for    | chewing gum regimen by preschool children and       |
| 3-5 year       | teachers in a Head Start program: A pilot study.    |
| olds.**        | Pediatr Dent. 23(1):71-74, 2001.                    |
|                |                                                     |
| **As part of   | Hayes C. The effect of non-cariogenic sweeteners on |
| the Head Start | the prevention of dental caries: A review of the    |
| program        | literature. J Dent Educ. 65(10):1106-9, 2001.       |
| requirements,  |                                                     |
| supervised     | ADA Positions and Statements. Role of sugar-free    |
| brushing with  | foods and medications in maintaining good oral      |
| a small smear  | health:                                             |
| of fluoride    | <http://www.ada.org                                 |
| toothpaste     | /prof/resources/positions/statements/sugarfree.asp> |
| will occur     |                                                     |
| daily, after a | ADA literature review and policies regarding        |
| meal.**        | consumption of soft drinks:                         |
|                | <http://www.ad                                      |
| **Note:        | a.org/prof/resources/topics/topics_softdrinks.pdf>. |
| Education      |                                                     |
| alone is not a | > [The following articles are all from the Journal  |
| best practice. | > of the California Dental Association, February    |
| Effective      | > 2003 and March 2003:]{.underline}                 |
| health         | >                                                   |
| education      | > Featherstone JDB et cal. Caries Management by     |
| includes       | > Risk Assessment: Consensus Statement, April 2002. |
| motivational   | >                                                   |
| interviewing,  | > Featherstone, JDB, et cl. The Caries Balance:     |
| d              | > Contributing Factors and Early Detection.         |
| emonstrations, | >                                                   |
| and            | > Donly, KJ Fluoride Varnishes.                     |
| reinforcement. | >                                                   |
| Motivational   | > Lynch H and Milgrom P. Xylitol and dental caries: |
| interviewing   | > An overview for clinicians.                       |
| is a form of   | >                                                   |
| counseling     | >                                                   |
| that is client |  ![](media/image4.png){width="0.6756944444444445in" |
| centered,      | > height="0.45069444444444445in"}                   |
| involving more | >                                                   |
| listening than | > ***How?***                                        |
| talking and    |                                                     |
| encouraging    | Through Head Start, every child should receive a    |
| clients to     | yearly oral health determination. Every child at    |
| come up with   | this age should have a dental home identified.      |
| their own      |                                                     |
| solutions to   | Provide a fluoride varnish treatment every 3-4      |
| health         | months for children at high risk for dental caries. |
| behavior       | Given the high prevalence of dental caries in AI/AN |
| change.**      | children, most children will be classified as       |
|                | high-risk. Fluoride varnish treatments can be       |
|                | provided efficiently onsite at the Head Start       |
|                | center or in the dental clinic.                     |
|                |                                                     |
|                | Collaborate with families and the dental provider   |
|                | to get any needed dental treatment completed. The   |
|                | dental staff can provide dental sealants for the    |
|                | primary molars of any children who are at high risk |
|                | for dental caries. This can be accomplished with    |
|                | either traditional resin sealants or glass ionomer  |
|                | materials for less than cooperative patients. The   |
|                | dental program will recall the child as             |
|                | appropriate.                                        |
|                |                                                     |
|                | Through Head Start, and with the approval of your   |
|                | HSAC, 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 that is given with  |
|                | meals and snacks or during circle time. Head Start  |
|                | staff will need to work closely with the local      |
|                | dental staff to develop and implement these         |
|                | programs. 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.   |
|                |                                                     |
|                | -   Educate families about the importance of        |
|                |     xylitol in reducing future dental caries.       |
|                |     Reinforce that xylitol is a natural sugar that  |
|                |     is found in plants. Make sure you tell families |
|                |     that chewing xylitol now will even decrease     |
|                |     cavities in the permanent teeth because you are |
|                |     changing the level of cavity-causing bacteria   |
|                |     in the children's mouths. Develop a permission  |
|                |     slip (see resources) and obtain parental        |
|                |     consent from as many families as possible. The  |
|                |     program will run much more smoothly if all of   |
|                |     the children are involved.                      |
|                |                                                     |
|                | -   Train the teachers and staff about the xylitol  |
|                |     program.                                        |
|                |                                                     |
|                | -   Ideally, Head Start children should chew        |
|                |     xytlitol gum 3 times a day. This is already     |
|                |     happening in some Head Start programs across    |
|                |     the country. It is usually given after          |
|                |     breakfast, after lunch, and in the late         |
|                |     afternoon either during circle time or on the   |
|                |     way out the door.                               |
|                |                                                     |
|                | ![](media/image4.png){width="0.6756944444444445in"  |
|                | height="0.45069444444444445in"}                     |
|                |                                                     |
|                | Through Head Start, each child should be brushing   |
|                | daily after meals at school with a small smear of   |
|                | fluoride toothpaste. Purchase child size soft       |
|                | toothbrushes (these may be available through your   |
|                | local dental clinic) and a fluoride toothpaste with |
|                | the ADA seal of approval. Children should brush     |
|                | their own teeth after meals. (see paper on          |
|                | toothbrushes and storage) You can put the pea size  |
|                | dabs of toothpaste units needed on a paper towel.   |
|                | Each child takes his/her own toothbrush and swipes  |
|                | one dab of toothpaste from the paper towel.         |
|                | Children can brush in groups around a sink or       |
|                | during circle time, using music to time the 3       |
|                | minutes of recommended brushing.                    |
|                |                                                     |
|                | The following list of recommendations for education |
|                | should be reinforced by the various medical         |
|                | providers, dental staff, community health workers,  |
|                | Head Start, and other partners as identified in     |
|                | each community.                                     |
|                |                                                     |
|                | -   Educate families about the protective qualities |
|                |     of fluoride. Ideally, every child should be     |
|                |     drinking fluoridated water and have his/her     |
|                |     teeth brushed daily with a small dab of         |
|                |     fluoride toothpaste. Educate and demonstrate to |
|                |     families how to clean a child's teeth, being    |
|                |     sure to reinforce the importance of using       |
|                |     fluoride toothpaste.                            |
|                |                                                     |
|                | -   Educate families about the importance of        |
|                |     healthy snacks and limited exposure to sweets,  |
|                |     refined starches like chips and crackers, and   |
|                |     sweetened drinks. Reinforce to families that    |
|                |     pop does not belong in a preschooler's diet.    |
|                |                                                     |
|                | > ![](media/image1.png){width="4.0625in"            |
|                | > height="0.1875in"}                                |
+----------------+-----------------------------------------------------+