During much of the 1990s, Head

Start directors, staff and parents,

as well as the Administration on

Children,Youth and Families (ACYF) program specialists, reported that the number one health issue affecting Head Start

programs nationwide was access to oral

health services. Programs and parents

alike told us about children suffering in

pain, children who could not eat, or children who had speech and language delays

because they were unable to get needed

dental treatment. Even if parents were

able to find a dentist who would accept

Medicaid patients,they would have to wait

months for an appointment,or travel over

thirty miles to keep the appointment.

In March 1999, representatives from the

Head Start Bureau, Health Resources

and Services Administration (HRSA),

Health Care Financing Administration

(HCFA), and the Special Supplemental

Nutrition Program for Women, Infants

and Children (WIC) met to discuss an

oral health initiative that was being

developed by HCFA and HRSA. The

Head Start Bureau shared its concerns

about the lack of Medicaid providers

and listened to HRSA express its concern that low-income children experience a disproportionate share of dental

disease. After much discussion, it was

decided that while the most pressing

need was to get children necessary dental treatment, a long-term strategy

would be to prevent dental disease

from occurring in the first place. This

would require that all the federal partners, as well as Head Start staff and parents, work together to improve the oral

health of young children.

On September 16 and 17, 1999, the

“Head Start and Partners Forum on

Oral Health” was held in Washington,

D.C. Head Start staff and parents, training and technical assistance providers,

pediatric dentists, representatives from

local and state WIC programs, Medicaid,

Maternal and Child Health and Child

Care, and regional ACYF, HRSA, and

HCFA staff met to learn about oral

health. The purpose of the Forum was

to convene a group of representatives

from Head Start and other federal agencies, researchers, scientists, practitioners, parents, and advocates to discuss

the latest research and evidence-based

oral health practices, and to develop

strategies to implement these practices.

The Forum was unique to Head Start

for two reasons. First, three scientific

papers specifically written for the

Head Start and Partners Forum on Oral Health

By Robin Brocato, Head Start Bureau

Inside this Issue...

Surgeon General's Report on Oral Health ..........................4

Causes of Dental Caries and the Role of Good Nutrition .10

Oral Health Assessment and Dental Prevention ..............12

Access to Dental Care for Preschool Children .................14

continued on page 3

August 2000

Issue No. 69

HEAD START ®BULLETIN

enhancing head start communication

U.S. Department of Health and Human Services ★ Administration for Children and Families ★ Administration on Children,Youth and Families

May 2001 

Issue No. 71

www.acf.dhhs.gov/programs/hsb

®
Oral Health

2

Contents

Head Start and Partners Forum on Oral Health...............................................1

Surgeon General's Report on Oral Health .........................................................4

Oral Health in the WIC Program ..........................................................................5

HRSA-HCFA Oral Health Initiative.......................................................................7

Oral Health Forum Keynote Address: Dr.Therman Evans...............................8

Causes of Dental Cavities and the Role of Good Nutrition .......................10

Oral Health Assessment and Dental Prevention.............................................12

Access to Dental Care for Preschool Children ..............................................14

At the Forum: Participant Comments ...............................................................15

Feedback on the Forum ........................................................................................16

An Interview with Dr. John Rossetti ..................................................................17

Comments from Parents Participating in the Oral Health Forum .............19

You've Been to the Forum (or Read about It): Now What? ........................20

Oral Health: Integrating New Science into Daily Practice............................21

Oral Health Update: Region IIa QIC..................................................................22

Feedback on the Forum: Region I.......................................................................22

Region VII Activities in Oral Health....................................................................23

Oral Health Initiative Activities in Region VIII..................................................24

New Mexico's Dental Health Summit 2000: Region VI-b..............................25

Toothbrushing and Head Start:What's It All About?......................................27

Why Bother? They're Baby Teeth........................................................................29

Fluoride Supplements: By Prescription Only!...................................................30

Something to Smile About....................................................................................31

The Implications of Culture on Oral Health Practices 

in Migrant Head Start Programs .....................................................................32

Oral Health Care Access Issues for Head Start's Indian Programs............34

Dental Coverage Under Medicaid......................................................................35

Bright Smiles, Bright Futures: New Oral Health Kit for Early Head Start ...37

HRSA Field Office Dental Consultants and Pediatric Dental Consultants..38

Resources .................................................................................................................39

Oral Health Virtual Resource Guide..................................................................40

Bureau Update: 2000-2001 National Head Start Fellows.............................41

The Head Start Bulletin is

published six times a year by the

Head Start Bureau, Administration

on Children, Youth and Families,

Department of Health and Human

Services. The Bulletin is a service of

the Head Start Bureau’s Training and

Technical Assistance Branch. Its

purpose is to enhance

communication among the Head

Start Bureau, Head Start programs,

and interested national, regional,

and state organizations and agencies. 

Tommy G.Thompson

Secretary

Diann Dawson

Acting Principle Deputy 

Assistant Secretary

Administration for Children 

and Families

Pamela Carter

Acting Director

Office of Public Affairs

James A. Harrell

Acting Commissioner

Administration on Children, Youth

and Families

Douglas Klafehn

Acting Associate Commissioner

Head Start Bureau

JoAn Knight Herren

Chief, T/TA Branch

Head Start Bureau

Traci Hefner

Managing Editor

Head Start Bulletin

The Head Start Bulletin is

prepared under Contract No. 105-96-

2010 with PaL-Tech, Inc.

Jean Swift

Co-Editor

Deborah Hamilton Kremer

Writer/Editor

Head Start Bulletin

Oral Health

Issue No. 71

Robin Brocato, Head Start Health Specialist, was the guest editor

for this issue.
Oral Health

National Head Start Bulletin ▼ Oral Health 3

Forum were sent to participants

prior to the Forum. At the

Forum, each paper was presented and participants were

given an opportunity to comment on the papers during

breakout sessions. Second,

researchers, practitioners, and

parents met face to face to discuss the feasibility of integrating

the research findings into 

daily practice. (Summaries of

these papers can be found on 

pp. 10–15.)

Partnerships with other federal programs serving children

and families are not new to Head Start. However, the partnership between Head Start, HRSA, HCFA, and WIC is

unique because it supports the larger DHHS Oral Health

Initiative and efforts to address oral health issues with constituencies at a regional, state, and local level. Furthermore,

each partner made a financial contribution to the development of one of the scientific papers, and committed to disseminating consistent messages from the papers to their

respective communities.

The Forum had three objectives—

1.To develop strategies to increase collaboration at the federal, state, and local levels and to develop and implement

strategies to improve oral health services to children 

and families

2.To present three scientific papers to participants about—

• current evidence-based oral health practices 

and recommended guidelines related to

nutrition 

• access to preventive and treatment

services 

• the prevention, management, and suppression of caries

3.To assess participant’s reactions to the scientific papers and the feasibility and cultural

appropriateness of implementing recommendations on local, state, and national levels

For each paper, Forum participants were asked the 

following questions— 

• What did you learn that was new and different? 

• Are the recommendations feasible? 

• What will you do with this information?

• What partnerships will you form to address these issues?

• What other comments do you have for the authors?

Participants also had an opportunity to address concerns

related to special populations such as infants, toddlers, pregnant women, and children with disabilities. They also

addressed the cultural implications of the recommendations.

On the second day, they met in regional groups to develop

action plans to implement after they returned home.

After the Forum, comments on each paper were compiled

and sent back to the authors for revision.The final papers

were published in the summer edition of The American

Journal of Public Health Dentistry. (See back page on how to

get copies of the journal or of individual papers).

In this issue of the Bulletin, you will find general information

that was presented at the Forum, summaries of each of the

three papers, participants’ reactions to the experience,

descriptions of follow-up activities that have taken place

throughout the country since the Forum, and oral health

resources. Enjoy reading about this unique and exciting

effort to improve the oral health status of children and families throughout the country.

Robin Brocato is a Head Start Health Specialist, Head Start

Bureau,T: 202-205-9903; E: rbrocato@acf.dhhs.gov.

Robin Brocato, Head Start Bureau

Patti Mitchell,WIC; Burton Edelstein, HRSA; Donald Schneider, HCFA; Betty DeBerry-Sumner,

HRSA.
Oral Health

4 Oral Health ▼ National Head Start Bulletin

“We have gone from a nation plagued

by the pains of toothache and tooth

loss to a nation where most people can

smile about their oral health.”

The recent report of the

Surgeon General discusses major findings in the area of oral health, which

the report stresses is essential to general health and wellbeing. It also provides a framework for action to enable us all

to make more progress in this field.

Most of us know that oral health involves our teeth

and gums.The report emphasizes, however, that oral health

means much more than healthy teeth. Oral health also

includes being free from chronic oral and facial pain, oral and

throat cancers, oral soft tissue lesions, birth defects such as

cleft lip, and other diseases that affect the oral, dental, and

craniofacial tissues.These tissues are the ones that allow us

to speak, smile, sigh, kiss, smell, taste, chew, cry out, and convey many feelings through facial expressions.

In addition to the theme expressed above—that oral

health includes more than healthy teeth—other themes form

the foundation for the rest of the report, including— 

• Oral health is integral to general health

• Safe and effective disease prevention measures exist that

everyone can adopt to improve oral health and prevent

disease

• General health risk factors, such as tobacco use and poor

dietary practices, also affect oral and craniofacial health

The Secretary of Health and Human Services asked that the

report, commissioned by the Surgeon General, “define,

describe and evaluate the interaction between oral health

and [quality of life] through the life span in the context of

changes in society.” The report covers the following topics—

• Part one outlines the meaning of oral health and provides

an overview of the craniofacial complex in development

and aging

• Part two describes the major diseases and disorders that

affect the craniofacial complex and gives an oral health status report card to the United States

• Part three focuses on the relationship between oral health

and general health and well-being

• Part four reviews how oral health is promoted and 

maintained and how oral diseases are prevented 

• Part five focuses on what we need to do to enhance 

oral health

One of the major findings of the report is that oral diseases

and disorders affect health and well-being throughout life.

These conditions and some of the treatments used to

address them sometimes undermine self-esteem, discourage

normal social interaction, lead to depression, and can possibly interfere with work, school, and family interactions.

Another important finding, especially relevant to the

Head Start community, is that there are profound oral health

disparities within the U.S. population.These disparities relate

to income, age, sex, race or ethnicity, and medical status. Not

everyone is informed of or can take advantage of appropriate health-promoting measures. Furthermore, social, economic, and cultural factors affect how health services are

delivered and used. One approach to improving access to

care involves making dental insurance more available.

Currently, public coverage for dental care is minimal for

adults, and programs for children have not been able to reach

all of the eligible beneficiaries.

Though we have made significant strides in oral health,

steps still need to be taken to improve quality of life and eliminate health disparities.The report describes a National Oral

Health Plan which provides a framework for action to—

1. Change perceptions regarding oral health and disease so

that oral health becomes an accepted component of 

general health

2. Apply scientific research to effectively improve oral health

3. Build an effective health infrastructure that meets the

needs of everyone and integrates oral health into overall

health

4. Remove barriers to care related to access, utilization,

financing, and reimbursement of services

5. Use public-private partnerships to improve the oral health

of those who suffer disproportionately from oral diseases 

As is evident from other articles in the Bulletin, creating partnerships is an especially important component for Head

Start.The report states that the collective and complementary talents of public health agencies, private industry, social

services organizations, educators, health care providers,

researchers, the media, community leaders, voluntary health

organizations, community groups, and concerned citizens are

vital if America wants to eliminate health disparities.

For more information and to read a full version of the executive

summary of the report, please go to www.nidcr.nih.gov/sgr/execsumm.htm.

Surgeon General’s Report on Oral Health

Oral Health in America:A Report of the Surgeon General—Executive Summary

United States Department of Health and Human Services
Oral Health

National Head Start Bulletin ▼ Oral Health 5

Oral Health in the WIC Program By Patti Mitchell

The WIC Program

can play an important

role in preventing

oral health problems

in women, infants,

and children through

its education and

referral programs.

The identification of

oral health problems

is part of the nutrition risk assessment

used by local agency

WIC staff to establish eligibility for participation in the

Program. Depending

on local priorities,

WIC local agencies

may provide nutrition counseling as well as classes to parents

and guardians of infants and children on proper care of the

gums and teeth at home and feeding

practices that reduce the risk of developing nursing bottle caries and other tooth

decay. Many WIC local agencies have

improved the links between participants

and the local oral health community

through referral and networking.

USDA’s Food and Nutrition

Service (FNS), which administers the

WIC Program, and WIC state and local

agency staff participated in the Head

Start and Partners Oral Health Forum

held September 1999. Several follow-up

activities are planned to disseminate

information regarding the Forum and the

recommendations made in the scientific

papers. For example, a working group of

representatives from FNS regional offices

and WIC state and local agencies around

the country has been formed to provide

guidance in developing materials for parents and WIC staff. These materials will

be based on recommendations from the

Head Start and Partners Oral Health

Forum and the scientific papers on nutrition and oral health.

At the federal level, USDA has

joined with other departments and agencies to participate in several initiatives in

an effort to further improve the oral

health of children, including participation

in and support of the Surgeon General’s

Conference on Children and Oral Health

that took place June 12-13, 2000.

WIC and Head Start:

Opportunities to Work

Together on Oral Health

Head Start programs can contact and

partner with state and local WIC agencies to obtain oral health educational

materials. Many WIC agencies have training modules, protocols for oral health

screening and referral, assessment tools,

and other oral health resources. For

example, the Washington state WIC

agency has an excellent oral health program.The Washington WIC Baby Bottle

Tooth Decay Prevention Project started

at a local WIC clinic and, in 1992, was

expanded statewide. Many other organizations and agencies in the state 

collaborated with WIC to develop the

project, including the Department 

of Pediatric Dentistry at the University 

of Washington.

The project has three goals: (1)

to promote nutrition and oral health

education to improve infant feeding

practices and reduce the risk of baby

bottle and early childhood tooth decay;

(2) to encourage caregivers to value

their child’s baby teeth; and (3) to provide oral health referrals when needed.

Washington state has numerous materials on oral health, including two publications—“Healthy Snack Tips”and

“Super Smart Snacks”—that provide

information on snacks that minimize

tooth decay. These materials can be

ordered via their Web site:

Dr. Peter Domoto, Dept. of Pediatric Dentistry, University of

Washington School of Dentistry, conducts a lap-to-lap examination to assess and prevent early childhood caries in a toddler.
Oral Health

6 Oral Health ▼ National Head Start Bulletin

www.doh.wa.gov/publicat/pubsdata.html. To search, enter

“dental/oral” as the subject.

Not all WIC agencies have specific oral health materials or projects,but FNS encourages Head Start programs to

inquire and, if needed, to collaborate with WIC to obtain

oral health resources for use in Head Start programs. By

coming together to identify needs and leverage resources,

WIC and Head Start may be able to find creative ways to

bring good oral health components to their programs and

into the lives of the families they serve.

One of the biggest problems facing local communities is finding dentists and oral health care programs willing to serve low-income participants. Head Start and WIC

can work together to publicize this concern in their local

areas, identify oral health care services and referrals, and

share this information with each other.Working together,

the two programs have more power to raise awareness

that oral health and access to oral health care are priorities in their communities.

Patti Mitchell is a Nutritionist, Supplemental Food Program

Division, Food and Nutrition Service, U.S. Department of

Agriculture,T: 703-305-2741; E: patti.mitchell@fns.usda.gov.

A Success Story

A survey of Head Start children in nine villages of the

Yukon-Kuskokwim Delta Region of Alaska found that an

average of 67 percent of children had baby bottle tooth

decay. Both WIC and Head Start staff found that children in Alaskan Native cultures are more often and

more consistently given sweets and soft drinks compared to non-native children.This emphasized the need

for educating parents and caregivers regarding nutrition

and its relationship to maintaining good oral health.

The Yukon Kuskokwim Health Corporation

(YKHC) WIC program initiated a demonstration project

to address this issue. WIC and Head Start staff 

conducted home visits to provide training that placed

special emphasis on nutrition education to parents and

caregivers, tooth brushing and flossing, and referral 

information on oral health and nutrition.Tooth brushes,

posters, pamphlets, and a video were distributed.

The project resulted in improved access to WIC,

dental programs, Head Start, and other health programs in the region. It enhanced nutrition services and

nutrition education and improved coordination among

health providers of these programs by giving them

experience in a new approach to collaboration efforts.

The project also raised awareness in the community of

the prevalent, painful, yet preventable problem of baby

bottle tooth decay.

Possible Areas of Collaboration

between WIC and Head Start

• Invite representatives from WIC to attend

your local, state, regional, and national

meetings

• Develop joint staff training opportunities

• Coordinate health and nutrition screening/assessment

• Share staff

• Exchange education approaches and share

educational materials

• Cosponsor community resource fairs and

community information sessions

• Encourage contributions to WIC and

Head Start Bulletins and newsletters
Oral Health

National Head Start Bulletin ▼ Oral Health 7

HRSA-HCFA Oral Health Initiative 

By Candace M. Jones

The HRSA-HCFA Oral Health Initiative

was inspired by the recognition that

dental access is a problem for families

enrolled in Medicaid and SCHIP.

According to a 1996 Office of

Inspector General report, only 18 percent of Medicaid children visited the

dentist.A meeting in Lake Tahoe in June

1998 was the genesis of this initiative. It

has resulted in an interagency agreement between the Health Resources

and Services Administration (HRSA),

the “access agency”, and the Health

Care Financing Administration (HCFA),

the agency responsible for the public

financing of Medicaid, Medicare, and the

State Children’s Health Insurance

Program. The Interagency Oral Health

Initiative aspires to eliminate access disparities and to advance the oral health

of all Americans, particularly those

most vulnerable due to age, income,

race, or special needs. A three-part

strategy was developed to—

• maximize the federal role in access

to care,

• partner with the private sector and

states, and 

• maximize prevention through science

transfer.

A team of Medicaid dental consultants at

the central and regional levels, public

health dentists, dental hygienists, and

pediatric dentists has been instrumental

in the activities of the initiative. Since its

inception in 1998, the initiative has made

a number of valuable contributions to

oral health promotion, including—

• convening or encouraging 24 state

coalitions or “oral health summits”

that focus on access to care and the

elimination of oral health disparities

• developing a home page (address

located at the end of this article) that

contains a Web based “tool box” for

states and advocates to use in

reforming dental programs. The tool

box includes—

• actuarial models

• workforce models

• geographic mapping

• model contract language

• policy briefs

• participationg in various aspects of the

Surgeon General’s work-shop and

conference on oral health

• assisting with the development of the

first Surgeon General’s Report on

the Oral Health of America

• raising the issues of oral health disparities and lack of access to care

with the Secretary of Health and

Human Services,resulting in a departmental oral health initiative

Through the various bureaus within the

HRSA and through the operating divisions within HCFA, a new emphasis on

oral health has been achieved:

• The Bureau of Primary Health Care

has increased the number of

providers and the number of community and migrant health care centers providing dental services.

• The Maternal and Child Health

Bureau (MCHB) has actively focused

on children and families through

school-based sealant and fluoridation

programs and increased training for

dental and medical providers offering

critical health services to young children and their families.

• HCFA has created a special technical

advisory group to explore ways to

improve the quality and quantity of

services for low-income families in

partnership with states. They have

also initiated a research program on

the cost-benefits of early prevention,

and provided assistance to states on

reforming Medicaid and implementing

SCHIP dental programs.

The HRSA-HCFA Oral Health Initiative

is eager to help promote regional and

state activities that address the oral

health of America’s youngest children.A

list of regional HRSA field consultants

and pediatric dental consultants to the

HCFA regional offices has been sent to

each ACF Regional Office health liaison

and QIC health specialist. Contact your

Regional Office or QIC for more information on assistance available for 

your program.

For more information on the

HRSA-HCFA Oral Health Initiative, go

to the web at: www.hrsa.gov/oralhealth.

Candace M. Jones is Deputy Director

Program Operations,Division of Oral Health,

Office of Health Programs, Dental Program,

Indian Health Service, T: 301-443-1106;

E: jonesc@hqe.ihs.gov.

“This unique gathering of

Head Start staff and parents,

dentists and other health care

providers, representatives

from Medicaid and WIC,

researchers, and others is an

opportunity to explore new

ways of working with partners to tackle issues of access

to health services.”

Tom Schultz

Director of Program Operations

Head Start Bureau
Oral Health

8 Oral Health ▼ National Head Start Bulletin

After battling severe weather and

employing multiple modes of transportation—an airplane, a train, a bus

and a taxi—Dr. Evans arrived in Washington 17

hours later. For the Forum participants, Dr.

Evans’ efforts were truly appreciated. He delivered an inspiring and thought provoking

keynote address to an audience of 120 participants, each of whom had also braved the elements to attend. His central theme was that to

truly address the problems of how health care

is delivered today—including oral health

care—we must take a holistic approach to creating health and wellness in human beings.We

also must be willing to change.

Dr. Evans reminded the audience of the

role that humor plays in keeping our perspective through challenging times and in developing creative solutions to difficult problems. He

told us of how Einstein valued humor and

imagination. In fact, imagination requires

humor: humor leads to laughter, which promotes relaxation, which enhances imagination,

which leads to creativity, which stimulates productivity, which strengthens security, which

Oral Health Forum Keynote Address

Dr. Therman Evans

Therman Evans, M.D.

Dr.Therman Evans, founder and CEO of WholeLife Associates, Inc., is the former Vice-president and Corporate Medical

Director of the CIGNA Corporation, one of the world’s largest health care companies. He has served as Chairman of

the Mayor’s City Wide Commission on the Prevention of Teenage Pregnancy in Philadelphia; as a member of the Board of

Directors for The Wellness Council of America as well as on other boards; as a member of the Advisory Panel of the

National Association of Health Service Executives; and as President of the Washington, D.C. Board of Education. He has

published over 24 articles in various health journals and newspapers, including the Journal of the American Medical

Association, the Los Angeles Times, Ebony and Collegiate magazines. Dr. Evans is the author of five booklets called

“Prescriptions”, the host of a radio show called “Lifeline” in Philadelphia, Pennsylvania, and a pastor.

Dr. Evans, known as “Mr. Inspiration,” is one of the most exciting and dynamic motivational presenters in this country and

abroad. He addresses wellness (inclusive of fitness and nutrition), diversity, and stress and change management.
Oral Health

National Head Start Bulletin ▼ Oral Health 9

makes one more able to laugh. The more humor in one’s

life, the more creative one can be.And as Dr. Evans pointed out, being uptight and defensive has not solved our

health care problems yet, so we might as well relax—it just

may help us develop the creative solutions we need 

to address the intractable problems facing our health 

care system!

If Forum participants remembered one thing from Dr.

Evans address, it was likely to be the concept that “all things

are related.” To address oral health, we must look at the

overall health of a person. Similarly, to address the problems of our health care system, we must look at the whole

system of delivery—not just the medical solutions. In many

cases, we have had the medical solutions to health problems, yet we have not been successful in bringing the solutions to the people because we have not been looking at

the whole system—or the whole person. While we have

continued to advance in technologies, we still do not

understand the basics of dealing with human beings.To do

this in any meaningful way, we are going to have to change

the way health care is taught and the way it is delivered.

Dr. Evans talked about how we must begin to look at

health care, including oral health care, from a positive frame

of reference. We need to move away from the traditional

medical school training of seeing patients as only the diseased organ or set of symptoms they present, and toward

seeing each person as a whole human being. The human

condition is one of spirit, mind, and body. If we do not learn

to address all three aspects of a person, we will never have

an effective and efficient health care system.

Dr. Evans emphasized in his address that access to

health care is not just a function of available expertise and

close geographic proximity. If that was the case, those in

lower income neighborhoods surrounding urban medical

centers should be some of the healthiest people in the community. Access is also affected by human factors such as

whether people feel welcome or valued. People do not need

to be highly educated to have an innate ability to read body

language, and they can clearly read the signs of not being welcome or valued.We must teach our health care professionals

to set aside their discomfort and learn to connect with people.They must learn to be comfortable with feeling uncomfortable as they work with people who do not look like them,

act like them, or speak like them. Until we learn to do that, all

the medical solutions or medical credentials in the world will

not do what they are created to do.Ultimately,Dr.Evans contended, degrees do not mean much if you cannot connect to

another human being.

Just as we need to look at the individual holistically,

we must also look at the system of health and wellness care

holistically. Each part is unique and critical to the functioning of the whole. Oral health, for example, is critical to and

dependent upon general health. Dentistry is critical to and

dependent upon general medicine, nutrition, and cultural

norms.We must learn to understand and value each component of the whole.We must learn to partner, collaborate,

and connect as individuals and organizations to create a

truly effective, efficient system for health, healing,

and wellness.

We also must learn to become more comfortable

with change. Human beings, Dr. Evans reminded us, do not

like change—especially when they have a vested interest in

the status quo, as do many health professionals. However, if

we want to address the problems in the health care system,

we all must be willing to change. We must expect that

change will bring pain, yet once we get past the pain and

effort, we will have the kind of health care system and,

more importantly, health outcomes, that we can now only

imagine. Like delivering a baby, the pain is necessary and the

new life it brings is its own reward.
Oral Health

10 Oral Health ▼ National Head Start Bulletin

Head Start and Partners Forum on Oral Health:

Paper # 1: Causes of Dental Cavities 

and the Role of Good Nutrition

We all know that sugar causes cavities, but most of us do not

really know why. We also have heard that it is harmful for

infants and children to be put to bed with a bottle containing

sweetened drinks. A paper by dentist Norman Tinanoff and

nutritionist Carol Palmer entitled “Dietary Determinants of

Dental Caries and Dietary Recommendations for Preschool

Children” (published in the American Journal of Public Health

Dentistry, Volume 60, No. 3, Summer 2000) explains how 

frequently eaten foods containing a lot of sugar promote tooth

decay and how a child’s diet can be improved so that teeth 

are protected.

Here is the way it works. Bacteria, or dental plaque, can

attach to our teeth, feed on the sugars we eat, and produce

acid. A specific bacteria, called Streptococcus mutans, can be

transmitted from mothers to their children, and this bacteria is

able to produce great quantities of acid from sugar. This acid

can erode away the enamel on teeth. If sugar is frequently consumed, acid is formed over and over again and can readily lead

to cavities.

Therefore, if children suck on candies, lollipops, or throat

lozenges for long periods of time, their risk of tooth decay

increases—the sugar is staying in the children’s mouths longer,

giving the bacteria a longer time to produce acid. Equally harmful to children’s teeth is frequently drinking juice from a sippy

cup or bottle, especially at nighttime. Of course, many parents

frequently give their children juice throughout the day because

children like it, it is cheap, and juice is thought to be nutritious.

However, these juice drinks, and even “natural juices,” have

sugar, and just like candies and lollipops, consuming them over

a period of time can cause cavities.

The Prenatal Period

Pregnant mothers need to understand that even before their

child is born, they are having an effect on their child’s future

tooth decay. Because

children’s baby teeth

begin forming before

birth, pregnant

mothers can help

prevent future tooth

decay in several

ways. First, mothers

should ensure they

are getting adequate

nutrition. Developmental defects in

children’s teeth due

to poor prenatal

nutrition are strongly related to the development of tooth

decay later in life. Second, mothers need to pay special attention to their own oral health. Studies have shown that mothers

with tooth decay increase the risk of passing cavitycausing bacteria to their children. For these reasons,

pregnant mothers should make sure to follow the balanced

eating guidelines of the Food Guide Pyramid and maintain

proper dental health.

From Birth to One Year

Good nutrition is especially important for oral health during

the first year of life. Breast-feeding is good, not only because

it is good for the baby’s health, but also because it decreases

the chance of tooth decay.

As already stated, an important factor for early childhood tooth decay is the prolonged use of baby bottles containing sweet drinks, such as fruit juice or other sweetened

drinks. Children on a bottle should be weaned to a cup by

age one. As infants make the transition from breast or bottle to cup, it is important that they not be allowed to suck on

a sippy cup for long periods of time, and drinks other than

milk or water should be limited to meal times. Additionally,

pacifiers dipped in sugar, honey, syrups, or other sweets are

also a problem.

Children like sweet foods, but parents and caregivers

need to have influence over children’s food preferences. For

example, infants are more likely to accept nutritious food if

it is offered several times. Also, children who eat a lot of

sugar as infants are more likely to prefer sweet foods when

they are toddlers.

From One to Two Years

During the toddler period, children are forming eating habits

and are more able to eat on their own.We need to pay attention to food choices that are good for a child’s oral health.

For example, parents should give their child nutritious finger

foods, such as cheese and fruit, as snacks. Studies have shown

that children may reject a new food many times before they

accept it. Consequently, it is important to continue exposing

children to healthy foods by keeping them available. And

while parents and caregivers should provide children with

healthy foods, let children decide for themselves when and

how much to eat. By doing this, you are helping children

sense when they are hungry or full.

Also, one should avoid offering children sweet foods as

rewards for an action or good behavior, which only reinforces a positive feeling about eating sweets.
Oral Health

National Head Start Bulletin ▼ Oral Health 11

From Two to Five Years

In the preschool years, try to reinforce good eating habits, including eating

at regular meal times and avoiding snacking throughout the day.As children

grow to be more independent, the patterns they were taught earlier in life

should help them make healthy food choices. Parents and caregivers can

also help children make healthy choices by limiting the availability of sweet

and unhealthy foods in the home.

Children with Special Needs

Children with special needs can be at increased risk of tooth decay due to

feeding difficulties and the use of sugar-based medications.Such problems can

lead to longer feeding times with foods staying in children’s mouths for longer

periods of time, increasing the risk of tooth decay. Therefore, parents and

caregivers need to pay special attention to the oral health concerns of children with special needs. Nutritional counseling can be very helpful in reducing the risk of tooth decay for these children.

Summary

Good eating patterns play a major role in children’s oral health, and parents and caregivers have an important role in developing these patterns.

They need to understand how frequently consumed sugar-containing food

can harm teeth.

This article is a summary of “Dietary Determinants of Dental Caries and Dietary

Recommendations for Preschool Children” by Dr. Norman Tinanoff and Carol

Palmer.The full text of this article is available in the Summer 2000 edition of the

American Journal of Public Health Dentistry as well as on the Web site:

www.hskids-tmsc.org.

Oral Health Dietary Guidelines for Expectant 

Mothers and Preschool Children

Dental Period Nutrition

Pregnant Women

Birth to One Year

One to Two Years 

Two to Five Years

• Follow the Food Guide Pyramid, taking into account increased needs

for pregnancy

• Take prenatal vitamin/mineral supplement as prescribed

• Limit intake of cariogenic foods, especially as between-meal snacks

• Avoid allowing infants to sleep or nap with a bottle

• Avoid excessive consumption of juice

• Eliminate dipping pacifiers in sweetened foods

• Avoid frequent consumption of juice or other sweet drinks in a 

bottle or sippy cup

• Encourage weaning from a bottle to a cup

• Continue avoidance of taking the bottle to bed

• Promote “tooth-safe” foods for snacks

• Foster routine eating patterns and following the Food Guide Pyramid

• Discourage slowly eaten, sweet foods, such as candy, lollipops,

or suckers.

• Promote “tooth-safe” foods for snacks

• Encourage eating at meals following the Food Guide Pyramid
Oral Health

12 Oral Health ▼ National Head Start Bulletin

Head Start and Partners Forum on Oral Health:

Paper # 2: Oral Health Assessment 

and Dental Prevention

Tooth decay remains one of the most

common diseases of childhood. Even

more troubling is the fact that lowincome children are affected by tooth

decay much more than are the rest of the

population. Therefore, Head Start, and

WIC need to take particular interest in

the oral health of their families and children. Dr. Michael Kanellis, in his paper,

“Caries Risk Assessment and Prevention”

(published in the American Journal of Public

Health Dentistry, Volume 60, No. 3,

Summer 2000), suggests that to lower

the rate of tooth decay in these preschool children, it is important to have

oral health as part of the structure of the

Head Start and WIC programs.

Screening

Oral screening exams for infants, toddlers, and preschoolers are

an important first step in

determining a child’s oral

health care needs. These

exams can provide important information on the

rate of current tooth decay

and the risk of future

decay.

Head Start Program

Performance Standards

require that Head Start programs provide dental exams

for their children within

90 days of enrollment.

Additionally, for those children in Head Start, Early

Head Start, and WIC, a

referral to a dentist should take place so

that “dental homes” can be established

for each child.

Risk Assessment

Screening exams provide an important

first step is determining which children

are at high risk for dental decay. They

help establish different preventive

strategies for each child. Children of

low-income status should generally be

considered at a higher risk of tooth

decay. However, it is still important

to conduct risk assessments at the individual level.

Risk assessment strategies that

are most effective are ones that are easily performed, are low cost, require no

special equipment, and provide reliable

results. Strategies that meet these

guidelines include—

• Review history — One of the best

indicators of future tooth decay is

past tooth decay.

• Look for cavities and white spot

lesions — Look for brown or black

spots that cannot be removed with a

tooth brush; white spot lesions (precavities) often follow the gum line.

• Look for plaque — The presence of

visible plaque on a child’s teeth indicates risk for tooth decay.

• Get a dental professional’s 

opinion — Dentists, hygienists, and

other health professionals can accurately predict a child’s risk for tooth

decay.

• Screen for bacteria —

Streptococcus mutans is the bacteria in

plaque that is necessary for tooth

decay to begin. Tests that look 

for these bacteria are good risk 

indicators.

• Ask about dietary habits—

Sleeping with a bottle containing

sweet liquids or letting a child suck

on a bottle or sippy cup throughout

the day are risk factors for 

tooth decay.

Prevention

After a child has been screened and his

or her risk of tooth decay has been

assessed, preventive strategies should

be planned. The following list of 

preventive measures are appropriate

for nearly every child in Head Start,

Early Head Start, and WIC.
Oral Health

National Head Start Bulletin ▼ Oral Health 13

• Education — Education has long been an important part

of preventive dentistry programs. However, studies have

shown that although education increases the knowledge

levels about oral health issues, it is often ineffective in making people change their unhealthy oral health behaviors.

• Tooth brushing — It has long been understood that

tooth brushing is an important means for reducing the risk

of tooth decay.Yet, what is even more important is making

sure that the toothpaste used with brushing contains fluoride. Preschool children should use less than a pea-size

amount of toothpaste. It is best for children not to rinse

or to minimally rinse after brushing to maximize the

effects of the fluoride.

• Fluoride varnish — Fluoride varnish is suitable for

young children at high risk for dental cavities. In some

states, dental hygienists can apply the varnish without

direct supervision. No special equipment is needed for the

application, and children can eat and drink right after a 

varnish application. Fluoride varnish applications can be

performed two times a year for all children, and more

often for children who are at a higher risk of tooth decay.

• Sealants — Sealants protect the pits and fissures of teeth

and are the single most effective means for preventing

tooth decay, especially for permanent molars in children

over the age of six.

Early screening, risk assessment, and preventive programs in

WIC, Head Start, and Early Head Start children are important because children in these programs are generally at high

risk for tooth decay and are sometimes unable to access 

preventive dental care through more traditional means.

This article is a summary of “Caries Risk Assessment and

Prevention” by Dr. Michael Kanellis.The full text of this article is

available in the Summer 2000 edition of the American Journal

of Public Health Dentistry as well as on the Web site:

www.hskids-tmsc.org.

Oral Health Prevention for Head Start 

and WIC Children

• Emphasize the importance of screening preschool children for tooth decay

to dentists, hygienists, nurses, physicians, and parents.

• Consider all children enrolled in Head Start, Early Head Start, and WIC at 

high risk for tooth decay.

• Help find a dental home for each child.

• Do not rely solely on education to help prevent tooth decay.

• Incorporate daily brushing with fluoride toothpaste into daily routines.

• Incorporate twice yearly fluoride varnish applications into preventive 

dental programs.
Oral Health

14 Oral Health ▼ National Head Start Bulletin

Head Start and Partners Forum on Oral Health:

Paper # 3: Access To Dental Care For 

Preschool Children

Children’s access to dental care is closely related to

age and income. Young children and low-income

children obtain far less care than others. Children

involved in Head Start and WIC programs often do

not receive dental services beyond screening and

nutritional counseling. When they do see a dental

professional, they frequently obtain less care than

they need to resolve all of their dental problems.

This problem persists even though most qualify for

dental coverage through Medicaid or the State Child

Health Insurance Program.

A paper written by Dr. Burton Edelstein

entitled “Access to Dental Care for Head Start

Enrollees” (published in the summer edition of the

American Journal of Public Health Dentistry,Volume

60, No. 3, Summer 2000) discusses the problems

that limit Head Start and WIC eligible children

from getting good dental care.These include problems stemming from Medicaid and SCHIP (burdensome administration, low fees, contracting

issues, and some limited benefits in SCHIP plans);

problems stemming from dental delivery systems

(few safety net dental facilities, dentists’ unfamiliarity with treating very young children, cultural barriers, and lack of dentists located close to children’s

homes); and problems stemming from

parents and families (lack of awareness

about oral health and dental care

needs, problems using the private dental care system, and competition from

other daily living activities). Because of

these barriers, low-income children

with dental problems often do not

receive adequate care. As a result,

these young children frequently have

high levels of disease and experience

dental pain and oral infections.

One of the first steps in solving

the problems of dental care for Head

Start and WIC children is screening to

identify obvious dental problems and

children at high risk of dental disease.

Head Start and WIC could also develop training

materials to advance and refine the approaches used

by dentists and other health professionals to screen

children and assess them for risk. By working with

dental schools,WIC and Head Start could develop

evaluation tools that measure the effectiveness of

screenings and assessments. By linking efforts with

safety net providers, particularly community health

centers,programs serving young children could help

integrate oral health services into overall primary

health care.

Head Start and WIC should also work with

local dental associations to encourage dentists to

support their oral health programs.With the local

associations, Head Start and WIC can arrange for

training programs that teach dentists and hygienists how to deal with young children and can provide social rewards for those engaged in seeing

the children they serve. Furthermore, Head Start

and WIC can involve parents in raising their

awareness about oral health and in preparing

them and their children for dental visits. For

example, dental visits should never be used as a

threat or punishment. Parents also need to be

advised of expectations about their use of dental

services, from appointment making and appointment keeping to office decorum and compliance

with oral health promoting recommendations.

Additionally, staff in these programs can help

tremendously to engage families in essential dental care by— 

• helping make dental appointments,

• assisting with transportation to dental offices,

• assuring child care for siblings during dental visits,

• accompanying concerned parents to the dental

office, and

• providing translation services.

Modern dental care offers children tremendous

and unprecedented opportunities to obtain and

maintain excellent oral health. Head Start and

WIC programs can go a long way toward reducing access disparities for young, low-income children by understanding barriers and removing

them in supportive and thoughtful ways.

This article is a summary of “Access to Dental Care for

Head Start Enrollees” by Dr. Burton Edelstein.The full

text of this article is available in the Summer 2000

edition of the American Journal of Public Health

Dentistry as well as on the Web site: www.hskidstmsc.org.

Dr. Burton Edelstein, Director, Children’s

Health Dental Project, Health Services and

Resources Administration.
Oral Health

National Head Start Bulletin ▼ Oral Health 15

At the Forum: Participant Comments 

Topic I:

Nutrition and Oral

Health 

Topic 2:

Prevention,

Suppression, and

Management of

Caries

• Working with the local dental community to obtain direct services and access

for families is a winning strategy.

Programs can involve medical professionals in observing dental health needs, and

can develop a tip sheet of key points that

staff can discuss when making contact

with medical and dental providers.

• Parents are key players in ensuring dental

care for their children. Programs should

work with employers to allow personal

leave for parents when taking their children to the dentist. Encouraging parents

to take children to the dentist by age one

is a strong message about the importance of dental care.

• Head Start staff should be given the tools

to promote oral health. Programs should

ensure that staff understands and implements the Performance Standards for

dental services, including payment and 

follow through.

• Oral health needs a higher profile.

Programs should prepare and deliver frequent, consistent messages to parents

about oral health.

• The Head Start community can influence

system and policy changes, such as incentives to work in rural areas, allowing 

dental hygienists to perform some procedures, and changing Medicaid claims forms

to make them less cumbersome.

• More research is needed on the cultural

habits of families, so that the approach

for implementing the nutrition 

recommendations can be tailored to

each culture.

• There may be challenges in implementing

the recommendations; however there

are many important steps programs can

take. Some strategies include—

• disseminating information to staff and

parents, (i.e., educating pregnant

women about good nutrition and its

effect on their own and their child’s

oral health),

• establishing or strengthening community partnerships with WIC, Title V

programs, and dental associations, and 

• revising policies and procedures that

reflect the recommendations are

important steps programs can take.

• Education about preventing caries is still

a viable option in Head Start.

• Educational approaches for both staff

and parent education include use of—

• non-print media such as videos or

CD-ROMs,

• educational kiosk programs,

• parent delivered education, and

• community access cable channels.

• Adults should be helped to overcome

their own fear of dentists.

• The feasibility of the recommendations is

affected by culture and special family 

circumstances.

Topic 3:

Access to Dental

Care for Head

Start Enrollees
Oral Health

16 Oral Health ▼ National Head Start Bulletin

Feedback on the Forum

By Judy Pulice

They say you are never too old to

learn. Although some days it seems I

am, that was not the case when I

attended the Oral Health Forum last

September. In fact, I learned a lot about

oral health during that day and a half.

First I had to throw out some of

my misconceptions, developed nearly

25 years ago, of how Head Start programs operate and how local programs

fit with state and federal activities and

oversight. Second, and most importantly,

I had to learn what is not working

when it comes to oral health and treatment for Head Start children.

Head Start is not unique in its

attempts to deliver dental care to poor

children, especially those between the

ages of two and five.The basic problem

encountered is the inadequate Medicaid

dental programs in most states. Funding

is often inadequate, the forms are cumbersome, and the policies do not make

sense to most dentists. Additionally, in a

majority of programs, the reimbursement rates do not come close to covering the costs of providing the services.

We can see why a great many dentists

have discontinued participation.

During the Forum, Head Start

program staff expressed their frustration and even anger at dentists in their

communities who are unwilling to treat

these vulnerable children. I understand

and empathize with Head Start staff. I

also, however, understand and

empathize with the dentists who are no

longer able to participate in a program

that is, it seems to them, beyond repair.

Members of the American Dental

Association often express their frustration and anger at state legislators and

officials who consistently underfund

their dental programs, either because

they do not believe dental care is

essential to a child’s well being, or

because they feel other services 

have priority.

At the end of the Oral Health

Forum, after meeting and talking with

so many program staff and federal

coordinators, I knew that not only had

I learned something, but so had the

other participants. Though they still

seemed frustrated and angry, they

promised to return home and contact

the local or state dental society to see

if they could work together to make a

change in the attitude of policymakers.

I hope they followed through. The

theme at several “access” conferences

lately has been community collaboration; it will take contributions from all

stakeholders to make the significant

changes needed. I am hopeful, in 

the case of oral health, we can 

work together to make the 

necessary changes.

Judy Pulice is Director, Department of State,

Government Affairs, American Dental

Association,T: 312-440-3520.

“This was the first time that these

federal agencies (Head Start,

USDA, HCFA, and HRSA) got

together to try to eliminate the

barriers to oral health care for

low-income families. The development of the papers and the real

world response from parents and

program staff will help us deliver

coherent messages to families and

programs that can be effective.”

“I was very impressed by the

knowledge of the Head Start

community about oral health.”

“The partnership has a lot of

potential. Certainly some work is

going on at the regional as well as

national level. Materials are being

produced for use by local programs. We are working hard on

improving the access to dental

care through Medicaid. The personal connections among the

partners should not be underestimated. We value the expertise

and commitment of all the partners and continue to review each

other’s work and ask for advice.

Head Start has a lot to offer the

dental community.”

Donald Schneider, DDS, Chief

Dental Officer for Health Care

Financing Administration.
National Head Start Bulletin ▼ Oral Health 17

1.Overall,what was your impression of the Forum? Did

you find anything particularly exciting, unique, or innovative? If so, what?

I was very excited about the Forum.We need more of this type

of activity. I still find it refreshing to see the enthusiasm that Head

Start programs and staff have for addressing critical issues.It brought

back fond memories of the annual training meetings and workshops

that Head Start and HRSA’s Maternal and Child Health Bureau

(MCHB) held for several years where training, data, and other information were shared between Head Start grantees and dental

experts. But, based on comments from participants, I am not sure if

appropriate oral health information is getting down to the grantee

level as well as it did in the past when Head Start and MCHB

worked together more closely. I think the understanding and dialog

generated at the Forum—cavities as an infectious transmissible disease, innovative ways to prevent dental disease, and the critical role

that diet and feeding practices play in dental disease—were very eye

opening to many participants.

Today, many Head Start programs are having greater difficulty accessing dental services and finding dentists to treat their children

than in the past.The Forum provided participants a great overview

of why this has happened. It’s obvious there is a maldistribution of

dental providers, and there may not be enough trained dentists to

treat young children.

Access to dental services for Head Start children is a problem

confronted by grantees all over the country, and it seems to be getting worse in some communities. Dental disease among many Head

Start children is not any better either. For example, a study done in

Maryland found that 50 percent of Head Start children had decayed

teeth and 90 percent of these children required fillings; 16 percent

of these children were in pain. In a similar study conducted in

California, 37 percent of Head Start children were found to have

urgent dental needs. How can children learn, be well-behaved, and

feel good about themselves when they are in constant pain? 

2. While Head Start and Health Resources and

Services Administration (HRSA) have worked together for many years on oral health (through the interagency agreement),this is the first time the partnership

has been expanded to include Women, Infants and

Children (WIC) and Health Care Financing

Administration (HCFA). Do you have any thoughts on

this expanded partnership? What do you think made 

it work?

None of us can do it alone. I think the partnership worked

because we recognized that oral health must be addressed comprehensively; each agency must be involved—each plays an essential

role.It is critical to have WIC participate in prevention and early intervention efforts, not only for children but for pregnant women as well.

Many children are seen by WIC before entering a Head Start classroom or being seen by a dentist.WIC has an important role to play

in reinforcing dental health concepts taught and practiced in Head

Start programs, but we need a mechanism to let WIC staff know

what is happening in Head Start. By working with families,WIC is in

a unique position. If a pregnant mother has active tooth decay and

her children have decay, chances are pretty good that the next child

born will also have tooth decay. Knowing this, WIC staff can be

trained in prevention and early intervention that would have enormous benefit to both the mother and the child. HCFA’s involvement

is critical because of its role in financing dental services—services

that can be provided by Head Start and WIC staff. HRSA also offers

valuable expertise in providing information and training on oral

health education, prevention, early intervention, and treatment.

There are HCFA staff at the national and regional levels who

are working very hard to overcome the access to care barriers and

their efforts seem to be paying off.After several years of inertia, we

are beginning to see some movement by states to increase dental

fees and remove some of the paper work and administrative barriers that have kept dentists out of the program. But, we have only

begun the process and have a long way to go to make Medicaid a

program that the dental providers will readily accept. I strongly recommend that grantees and state level Head Start organizations

work much more closely with Medicaid and SCHIP staff. If a state

level Head Start organization has an advisory committee, Medicaid

or SCHIP representatives should be asked to be members.If they say

no, ask again.

3. You have worked with Head Start programs for over

25 years. Have the training and technical assistance

issues related to oral health remained the same, or

have they changed? If they have changed, what are the

emerging issues?

As I mentioned,for many years MCHB administered an agreement with Head Start to provide technical assistance to grantees on

prevention, early intervention, and access to oral health care. We

maintained over 200 dental consultants and experts to work with

grantees on all aspects of oral health.The agreement no longer exists,

but the issues are basically the same—with a few noteworthy

changes.We have always had higher disease rates in Head Start

Interview with Dr. John Rossetti

Chief Dental Officer, Maternal and Child Health Bureau

Chief Dental Officer, Health Resources and Services Administration
18 Oral Health ▼ National Head Start Bulletin

than in the general population, and the need for prevention, early

intervention, education, and access has been with us for a long time.

But for some programs, the situation may have worsened.

Today it is more difficult to access providers and there are

fewer dentists willing to treat Head Start children than in the past.

This may not be the case everywhere but the feedback that I get

from many states reinforces this point. Nationally, we are seeing

about 6,000 dentists retiring every year and only 4,000 graduating

from dental school, and we also see fewer and fewer dentists practicing in underserved areas where our Head Start programs may be

located.There is also a problem with the low numbers of pediatric

dentists.Low Medicaid fees also have been a problem for some time.

Until recently, there were very few states that raised their Medicaid

rates to attract dentists to treat Head Start children.

The distribution of oral health disease has also changed. Oral

health problems are more concentrated in a smaller proportion of

children than in the past. Currently, 80 percent of the dental decay

is concentrated in 25 percent of the children.These children are usually from low-income families, families with low parental education,

and recent immigrants—the same 25 percent that are Head Start

children.The general public, many providers, and policy makers do

not think oral health is a problem.They do not see it in their children

so they think it no longer exists. But

we all know they are wrong.We see

it every day.

Some people may not see or

experience it,but dental decay is the

most prevalent chronic disease in

children in America today. The fact

that the organisms that cause dental

decay are transmitted from caregiver to child (and are also affected by nutrition and hygiene) is a new

concept to many.This goes back to what I said about the need for

greater involvement of WIC in prevention and early intervention programs.We know how to prevent it and intervene early in the disease

process,but we have not been using the tools that we have.The right

people have to be made aware of these tools and be trained to use

them if we are to gain control of the problem.

During my 25-year involvement with Head Start, I have provided direct dental care to Head Start children, taught in the Head

Start classroom, conducted teacher training, managed regional technical consultants and been a national advisor/consultant to the Head

Start Bureau.These have been very enjoyable and rewarding years

for me. During this period I have observed much about the Head

Start program, its children and families, and I have also developed

several opinions and philosophies. Today Head Start puts greater

emphasis on parents or caregivers getting the child to the dentist for

needed care instead of having Head Start programs access care for

the children. Unfortunately, we’re finding that many children aren’t

always getting to the dentist. As we discussed earlier, it’s much more

difficult to get an appointment today for a Head Start child on

Medicaid than it was 15 to 20 years ago. It’s great to get parents

involved, but if they fail to follow through or just can’t get a dentist to

see their child, it is the child that suffers—the child falls through the

cracks. In the past, programs made the appointment and ensured

that children received care.We can’t have kids falling through the

cracks.We may need to go back to having programs take a more

active role in getting children to the dentist.

Most of us tend to think of parents as the teachers of their

children, but I have found that children can be teachers of their parents and siblings as well. When Head Start children learn proper and

regular oral health habits in the Head Start classroom,they bring this

information and healthy habits home to their families. I have had

many Head Start parents come into my dental clinic after years of

dental neglect because their child came home from Head Start and

told them how important it was to take care of their teeth and that

they shouldn’t be afraid of going to the dentist.

With respect to the emerging issues, we are now much more

aware that children with a high level of decay in their baby teeth are

probably going to have a lot of decayed adult teeth.We also recognize that the bacteria that cause tooth decay are transmissible—

most likely from the mother or caregiver to the child.We also know

that we can stop or slow down the decay process once it begins.This

lends strong support for training and utilizing Head Start and WIC

in dental screening and early intervention techniques.We are exploring the use of fluoride varnish application as one of the things that

Head Start and WIC staff can do to address the problem.

4. In your opinion, what are the challenges that Head

Start and Early Head Start programs face in implementing some of the preventive practices presented at

the forum? What steps can

programs take to overcome

these challenges?

Just getting things started will

be tough. The challenge is to put

more emphasis on early intervention. We need more training and

technical assistance for local programs. We need more dental

providers on health advisory boards to provide training and technical

assistance to programs, and hopefully become providers of dental

care for Head Start children.

We need to get parents involved in getting their children to

dentists, or if parents can’t do it, find ways to get care for children

through the Head start programs (by taking groups of children to the

dentist,for example).The challenge is to get kids to leave Head Start

with good oral health habits and attitudes toward oral health and

ensure they continue healthy habits and routine dental care once

they leave Head Start.

We need to get WIC, the dental community, and the pediatric

medical community involved. The pediatric community could help

enormously. For example, they could provide oral health guidance to

Head Start parents, they could better screen children for dental disease, and apply fluoride varnishes. In general, we need better utilization of the private sector medical and dental community.

5. Do you have any final thoughts on the Forum, the

partnership, or the recommendations?

We need more Forum-type meetings around the country.Over

a decade ago, we routinely held regional workshops similar to this

one.We should do that again.I’d also like to see a rejuvenation of the

collaboration between HRSA and Head Start on a formal basis,

maybe including WIC and HFCA.

Most of us tend to think of parents as

the teachers of their children, but I

have found that children can be teachers of their parents and siblings as well.
Oral Health

National Head Start Bulletin ▼ Oral Health 19

The Oral Health Forum benefited from

the participation of several parents

who offered valuable input to the discussion.As one of the parents said, she

was able to bring daily “real life” health

information, concerns, and problems to

the discussion. The parents also were

an important conduit back to their programs and communities.

Tracy Kennedy, chair of the Head Start

Parent Policy Council in Litchfield,

Connecticut, said she took what she

learned at the Forum and applied it that

night with her family.Tracy enjoyed sitting

and sharing her thoughts with educators

who worked in the field of oral health.

She found it gratifying that her opinions,

as well as the opinions of other parents,

were listened to by the experts.

Tracy also found it exciting to be on the

cutting edge of oral health information.

She was particularly interested in the

research on cavities as a disease—a concept unfamiliar to her before the Forum

and important to her as a parent. She

was excited to learn that oral health

actually begins before birth and that a

woman taking care of her teeth while

pregnant has a positive effect on her

unborn child. Although some of the

information presented was scientific, the

sessions helped her understand the concepts and provided an opportunity for

her to speak with experts “on the same

level.” She knew that her input was valued since she was able to discuss the

daily concerns and problems that average

parents face—a critical aspect to any oral

health practice.

Melissa Scott, a parent representative

who works with the Olympic Education

Service Department in Bremerton,

Washington, attended the Forum with

the hope of learning how to get dental

services to small communities and

remote areas like Alaska—she had lived

in remote areas where dental care was

hard, if not impossible, to find. Melissa

found the experts at the Forum to be

very open. While following the medical

jargon used by some of the presenters

was difficult at first, they did a good job

of explaining the terms and why it was

important for people to be familiar with

the terms. By the end of the presentations, Melissa was comfortable with the

new jargon and information she had

learned. Melissa was honored to have

been asked to participate in the Forum,

and felt that her interest and work in trying to get oral health services to young

children in remote areas was valued by

people at the Forum.

Comments from Parents Participating in the

Oral Health Forum

“Excellent idea to include

Head Start parents—it is

rare for agencies to

include those persons who

actually receive the 

services. People don’t 

realize they can learn a

great deal from them.”

-Agency Participant

“ I learned a great deal of

information from people

other than my usual colleagues—from parents

and people who work with

children on a daily basis.”

-Dentist Participant
Oral Health

20 Oral Health ▼ National Head Start Bulletin

You’ve Been to the Forum (or Read About It): 

Now What?

By Robin Brocato

As the planning committee for the Head

Start and Partners Forum on Oral Health

met, one topic of discussion was what

follow-up activities would take place

after the Forum. Planning committee

members envisioned the Forum being

replicated on a regional, state, and local

level, and in fact, this has taken place in

several regions and states (see articles on

pages 22 through 26 about some of these

events).While we know that no community or state is exactly alike, and no 

forum will replicate the September 99

Forum, here are some steps that you can

take to get your community or state

more involved in oral health—

• Contact your Administration on

Children and Families Regional

Office.They may already be working in

partnership with the regional HCFA or

HRSA office.They may be able to assist

you in identifying regional, state, and

local resources, or may be able to share

what other Head Start programs in

your region are doing to improve

access to oral health services.

• Contact your Regional Quality

Improvement Center Health

Specialist. The QIC health specialists

have been working on this issue for

many years.They can identify state and

local resources and contact persons,

and can provide technical assistance as

needed.They also have a limited supply

of oral health buttons and posters they

can send you in support of local and

state oral health activities.

• Contact your State Collaboration

Office. Many of the state collaboration

offices are working on health issues such

as improving access to care or

Medicaid/SCHIP outreach. Ask them if

they have information about state interest in or activity on oral health.They may

also have names of state or local contact

persons from HCFA, HRSA, or WIC.

• Take this opportunity to revisit

formal and informal community

partnerships. If you have an existing

interagency agreement (state or local)

with either WIC or HCFA (Medicaid),

look over the agreement to see if it is

broad enough to cover oral health, or

think about how it could be revised to

do so. If you rely on informal 

partnerships with your local health

department or other community health

providers (such as a managed care

organization), think about the pros and

cons of formalizing the partnership.

• Involve your Health Services

Advisory Committee. Recruit a dentist or dentists to serve on your HSAC!

Provide copies of the papers presented

at the Forum to your HSAC (for information on how to get copies of the

papers, see page 44) and ask them to

help develop a plan to implement some

or all of the recommendations.They may

also be helpful in contacting state dental

schools to ask them to get more

involved with Head Start.

• Let technology work for you. In

this issue of the Bulletin, several

resources are presented.Visit the Head

Start Oral Health Virtual Resource

Guide at: www.hs-kids.tmsc.org (see

page 40 for a description of the guide).

Ask your HSAC for assistance in deciphering the vast information available

on the Internet, keeping in mind that

the source and quality of the information is very important. Download pamphlets, fact sheets, and articles from

reputable sites; copy them and give

them to parents.

• Speaking of parents, do not 

forget the Policy Council! Copy

some of the articles in this issue of the

Bulletin, provide parents with copies of

the papers, or view the actual videos

from the Oral Health Forum. Have a

parent meeting dedicated to the topic

of oral health. Invite health staff, HSAC

members, and community providers to

watch the videos or discuss the Forum

papers and this issue of the Bulletin.

Robin Brocato is a Head Start Health

Specialist, Head Start Bureau, T: 202-205-

9903; E: rbrocato@acf.dhhs.

Visit the ACF Head Start Website at:

www.acf.dhhs.gov/programs/hsb for information on how to reach your Regional Office,

QIC, or State Colloboration Office.

By Sue Wilson

Head Start Fellow, Class of 2000

Forum participants gave useful suggestions

for how to make the most of your Health

Services Advisory Committees (HSAC)—

HSAC members can be important

resources for programs—

• Include a dentist on the Health Services

Advisory Committee

• Involve Medicaid consultants on the HSAC

Finding dentists to serve on your

HSAC can be challenging—

• Look for retired dentists and pediatric

dentists

• Approach dental societies, Kiwanis or

Rotary Clubs, American Academy of

Pediatrics, Healthy Child Care America,

and health consultants for suggestions

The HSAC can play an important role

in implementing the recommendations in the Forum’s papers—

• Use the HSAC to sort through the

research and information received from

experts before implementation

• Ask the HSAC for advice and assistance

on incorporating realistic activities

• Ask the HSAC for technical advice such

as—

• Whether chlorhexidine is useful for 

children,

• If Head Starts can request the dental 

history of mothers, and

• If programs should encourage applying

varnishes twice each year.
Oral Health

National Head Start Bulletin ▼ Oral Health 21

How do we integrate new scientific

findings into what we do and how we

do things at our Head Start centers?

This is a common question for participants at research conferences as they

return to their Head Start programs

armed with new knowledge as well as

the desire, hope, and enthusiasm to

share the information they know will be

helpful to children and families.

Many participants left the

September 1999 Oral Health Forum

with that very question in mind. The

Head Start Bureau and its partners had

provided summary recommendations in

three areas of research—nutrition and

oral health, prevention, and access to

dental care (summary papers can be

found on pages 10 to 14 of this

Bulletin).The far-reaching recommendations outlined strategies for incorporating the new science discussed at the

Forum into daily practice.

The Challenges

When Head Start staff returned to

their centers, some common challenges

were echoed from Maine to California:

What are these new findings? How can

we get the word out? People will not

understand why they should change the

way they do things. How can we show

people how these activities can benefit

expectant parents, children, and ultimately families? Folks will not want to

change what they do,since their parents

did it the same way. Medicaid will never

increase reimbursement so providers

can cover their costs.Is it really possible

to integrate medical and dental systems

to provide continuity of care?

Addressing the Challenges

At a minimum, it will take four steps

to address the challenges of integrating new science into the daily 

practice of oral health at Head Start

centers— 

1.Identify the challenges to implementing the new science as a priority for your center.

2.Plan two or three approaches to

addressing the specific challenges.

Prioritize them.

3.Implement your priority plan of

action using all appropriate strategies.

4. Evaluate the outcome of your implemented plan. Determine if the new

science is being practiced as intended.

Implementing the Change

The details of a sound plan are what

make it successful. Therefore, it is

important to consider the following

when implementing the plan—

• Assess the audience for whom the

new science is intended. Is it Head

Start staff, expectant women, children,parents,or oral health providers

you want to inform about the new

science? Clearly articulate how the

new science will benefit the audience.

• Plan the approach based on where

the audience “is.” Include representatives of the audience in the planning process. Consider the following

questions—

• What practices do the audience

currently use?

• What change will be necessary

to incorporate the new science

into daily practice?

• How will the audience receive

and integrate the proposed

change today, tomorrow, and

from now on?

• Deliver only one change in practice

at a time. For example, introduce

only one new food to a toddler at a

time. Be sure to provide the change

in an acceptable—or “bite size”—

dose.

• Assist people in replacing old ways

with new ones by providing strategies for incorporating the change

into the way daily practices have

been conducted in the past.

• As change is implemented, provide

positive feedback and encouragement to those who have begun to

use a piece of the new science on a

routine basis.

The Outcomes

When implemented, the recommendations from all three scientific sections of the 1999 Oral Health Forum

will fuel a high quality, comprehensive,

coordinated, culturally competent

American system of oral health care.

The only challenge remaining in this

future utopia will be where to find a

carious tooth as an example for dentists in training!

Dorothy Allbritten is a Pediatric Nurse

Practitioner and Health Services Manager,

Fairfax County Head Start, T: 703-324-

8124.

Oral Health: Integrating New Science into Daily

Practice: Perspectives from the Field

By Dorothy Allbritten
Oral Health

22 Oral Health ▼ National Head Start Bulletin

Feedback on Forum 

By Larissa Zoot

For me, the highlight of the Head Start

and Partners Oral Health Forum was

meeting service providers who had

previously been involved with the

Head Start program as children. In the

midst of discussing the challenges of

accessing quality oral health care, it

was such an inspiration to meet

terrific, dynamic, professional adults

who fondly remember how Head

Start positively affected their lives, and

who are now dedicated to giving

something back by serving current

Head Start families. Perhaps together

we can address the challenge of 

finding pediatric dentists and other

providers with the training and willingness to work with our most underserved populations.

The image of “climbing a ladder

with one hand reaching up to new

accomplishments, and the other hand

reaching back down to help others in

their climb” reinforces for me the spirit

behind all our efforts in oral health.

The strongest message I carried with

me from the Forum’s Region I breakout session was that it is just such

leadership at the local level which will

be instrumental in reaching our goals.

On August 23, 2000, there was a

meeting of the regional T/TA health

specialist, the regional health and disabilities liaison, and health services

managers from Head Start and Early

Head Start programs in the region.The

meeting served as a brainstorming and

planning session for initiatives targeting oral health.

Larissa Zoot is a EHS Specialist/Health &

Disabilities Liaison, Region 1, New England,

T:617-565-1153;E:lzoot@acf.dhhs.gov.

Region IIa is working hard and 

testing a variety of different activities

to improve oral health care for Head

Start children.

Representatives from the Region II

Administration for Children and

Families, Regional Office, Head Start

Quality Improvement Center IIa, New

York Dental Society, New York State

Head Start Collaboration Office, and

Head Start programs met to discuss

ways in which they would collaborate

on oral health issues. They agreed to

pursue the following—

• Inviting health managers to local

meetings of the New York Dental

Society (NYDS) to discuss the oral

health problems of Head Start

children

• Encouraging health managers to

invite a dentist from the NYDS to

attend Health Services Advisory

Committee meetings

• Sharing information about Head

Start at NYDS annual meetings

and information about NYDS at

Head Start meetings

• Exploring ways to establish training for staff and parents on the

best ways to access local dental

communities

Additionally, two New Jersey programs will be chosen to participate

in a pilot project on oral health. Each

program will work with a dental consultant to train staff in oral health

issues and to work on developing a

dental health plan. The dental plan

will include creative ways to ensure

that each child has a dental exam,

dental treatment, and a dental home.

The QIC is also planning a dental

screening initiative for programs in

New Jersey.This program, headed by a

QIC dental consultant,will teach Head

Start staff how to perform initial dental screenings on children. The purpose of this program is to ensure that

children with advanced dental problems are referred to a dentist as soon

as possible.

Jeanne Zozobrado is a Health Specialist,

Head Start Quality Improvement Center,

New York University, T: 800-336-4848;

E: jzozobrado@aol.com.

Oral Health Update: Region IIa QIC

By Jeanne Zozobrado

From Research to Practice

By Stuart Reynolds

Child Inc., Austin,Texas

According to Stuart Reynolds of Child Inc., folks in Austin,Texas are putting

research to practice.“One of the most immediate changes that we will initiate will be to develop a procedure to screen and examine all children beginning at one year of age.This will affect nearly 50 infants currently enrolled in

our Early Head Start program. As a result of what we learned at the Oral

Health Forum, we will add several key messages to our annual in-service

training for teachers and to our parent workshops on dental health.

Specifically,we will highlight that dental caries can be considered an infectious

disease and that mothers can expose children to the infectious streptococcus

mutan bacteria inadvertently through kissing or the exchange of saliva.The

training will also look at ways to prevent dental caries as described in the

research articles.”
Oral Health

National Head Start Bulletin ▼ Oral Health 23

In July, 1999, Region VII Head Start began expanding its 

capacity to ensure quality oral health services for children and

families in each state.This growth was sparked by exceptional

collaboration among organizations and individuals, all committed to the same goal.The information and excitement generated at the National Oral Health Forum, held in Washington,

D.C., in September 1999, served as a catalyst for our work.

Many strategies are being used to accomplish our goal.

Each state Head Start Association and Community

Development Institute (Region VII QIC) conducted a survey to

document the access to dental care in each county.The survey

results have been used to communicate information pertaining

to the barriers to oral health care to legislators, Medicaid staff,

and dental associations. Iowa Head Start Association incorporated the data in a resolution for state political leaders and the

Iowa Dental Association signed the resolution.

Each state Head Start association has addressed prevention and access issues for children at risk.Two state associations have held oral health caucuses with state government

leaders, politicians, dental professors, dental association executive directors, and dental hygienist association board members.

In each state, the Head Start collaboration director has played

an active leadership role in building and sustaining the partnerships with these individuals and groups.

In July 1999, the Community Development Institute

responded to the issue of oral health by creating an Early Head

Start Oral Health Demonstration Project.The goal is to determine what strategies community health partners and EHS staff

can use to ensure that each EHS child reaches his or her third

birthday without experiencing oral health problems.The study

will generate useful information about building community

partnerships and designing an effective curriculum to address

the oral health needs faced by EHS families.Three EHS grantees

in Nebraska are now implementing the project: Lincoln Action

Program (Lincoln), Central Nebraska Community Services

(Loup City and Columbus), and Salvation Army (Omaha). Dr.

Kim McFarland, Nebraska state dental director, has given her

support, and two pediatric dental professors have stepped forward with guidance and direct services to families.

Dr. Michael Kanellis, professor of pediatric dentistry,

University of Iowa School of Dentistry,has inspired his Masters

in Public Health dental students to address Head Start’s need

to better teach children to care for their teeth. For instance, in

May 2000, the UI faculty offered the workshop “Oral Health

Risk Assessment and Prevention for the Head Start and Child

Care Health Community.”

The Kansas Medicaid office gained a waiver from HCFA

so that Head Start can be Medicaid providers.This gives programs greater access to a wide range of dentists and saves the

program money. Even if they have to pay the full amount for

dental services from a non-Medicaid dentist, they can collect a

percentage by filing the Medicaid claims.

Missouri Head Start has accepted the lead in the state to

convene and facilitate the oral health education committee,

which is part of the statewide consortium to address access to

dental care. Chris Groccia, Head Start collaboration director,

and several Head Start managers are active participants in 

this group.

At the Surgeon General’s Conference on Oral Health,

Dr. Diane Gastmann presented the Iowa Head Start Dental

Access Survey results. Thirty-six state government, political,

dental, and early childhood leaders from Kansas also attended

this conference. The group, sponsored by United Methodist

Health Ministries Fund,intends to hold a strategic planning session based on their learning at the conference. Head Start is

represented in this group and will offer strategies for grantees

to play a significant part in improving access to oral health in

the state.

As a result of the regional and state activities, Region VII

Head Start anticipates improved access to quality oral health

care for high-risk children. In addition, all of our grantees are

committed to increasing their roles in prevention, oral hygiene

for children and families, and parent and community education.

Marcia Manter is a Professional Development and Health

Coordinator, Community Development Institute, Region VII Head

Start Quality Improvement Center, T: 816-356-5373, ext.13;

E: mmanter@aol.com.

Region VII Activities in Oral Health

By Marcia Manter
Oral Health

24 Oral Health ▼ National Head Start Bulletin

Oral Health Initiative Activities in Region VIII

By John Thomas

HCFA and HRSA staffs have been very

active in developing oral health initiatives.

Our three most significant activities to

date have been— 

• Participating in Comprehensive

Systems of Quality Care meetings in

two states, followed by dental specific

summits in Montana in November 1999

and North Dakota in April 2000. We

have found these meetings to be

extremely successful in raising state and

public awareness of the barriers to

accessing dental care, as well as for

developing cooperative relationships to

promote change. We believe they are

the most appropriate method for this

activity in this region.

• Providing technical assistance in developing Geographical Information System

(GIS) mapping data in three states

(Colorado, North Dakota, and South

Dakota) under a special one percent

HRSA grant. This data will help our

partners identify their primary areas of

need by geographic area and will serve

as a basis to design strategies to

improve access.

• Representing all ten HCFA regional

offices (ROs) on the Maternal and Child

Health/Oral Health Technical Advisory

Group and as the consultant for the

HRSA cluster representatives, as well as

examining federal policies that affect

access to provider enrollment and

access to care.

While our focus has been on these three

key activities, regional team activity has

not been limited to these areas. Examples

from other significant activities, classified

by state, region, and nation, follow.

John Thomas is a Health Resource Specialist,

Head Start Quality Improvement Center,

Community Development Institute, Denver,

Colorado, T: 800-488-2348, ext. 14;

E: John_Thomas@ceo.cudenver.edu.

Colorado

• Participated in two meetings initiated by the Rose Foundation to

coordinate efforts between the state dental association, department of health, and other key partners to obtain a comprehensive dental benefit package for their SCHIP

• Provided a dental initiative presentation at a rural health coalition

meeting to align their support and identify areas where we can

work together

• Participated in the evaluation of Anthem Blue Cross/Blue Shield

Foundation’s Miles for Smiles mobile dental van program

• Assisted in a local community effort to develop an outreach

campaign by identifying existing models of public service

announcements and informational materials, as well as

funding and development

opportunities

Montana

• Provided a summary of the HCFA/HRSA

Oral Health Initiative and the state dental

summit to the legislature’s health committee to encourage infrastructure support

• Monitored ongoing activities to develop the

state’s infrastructure and generate specific

strategies for the resolution of particular

barriers by providing technical assistance

and data support

• Notified the state of additional funding

opportunities for support of infrastructure

development. Subsequently assisted state in

writing Community Infrastructure Support

System (CISS) grant application. HCFA provided letter of support for project

North Dakota

• Participated in a second

forum addressing access to

care for the state’s

American Indians

South Dakota

• Developed information and reported on access to dental care as

part of the SCHIP implementation review August 1999

• Met with the president of the South Dakota Dental Association

to discuss opportunities to work together to address barriers

to access

• Worked closely with the state partners to amend the dental

practice act to allow dental programs to operate in community

health centers, and along with HRSA Central Office staff to

assign a USPHS Commissioned Corps officer to the program 
Oral Health

National Head Start Bulletin ▼ Oral Health 25

New Mexico’s Dental Health

Summit 2000: Region VI-b QIC

By Marilyn Smith

In January 2000, New Mexico’s Primary Care Association (NMPCA) coordinated a statewide forum sponsored by HRSA, HCFA, and the New Mexico

Department of Health’s Primary Care Bureau which brought together key

decision makers, state agencies, advocacy groups and other stakeholders.The

purpose of the summit was to identify barriers, discuss solutions, and build

broad-based support for the implementation of strategies to improve dental

health care access in New Mexico.

Over 110 participants attended the summit, including representatives

from various dental associations, the New Mexico public schools, HCFA, and

HRSA. Two legislators, several advocacy groups who represent children with

disabilities, Native American tribes and pueblos, and grassroots dental

providers attended as well.

The issue of dental health access for all New Mexicans regardless of

income is complex and challenging. Many dental health access issues had been

addressed prior to the summit through Senate Joint Memorial 21, which

amended the Dental Health Care Act by—

• allowing dental hygienists to work in “collaborative practices” with dentists

• explicitly requiring licensure by credential for dentists and dental hygienists

without practical or clinical examination for those applicants who are duly

licensed by clinical examination as a dentist or hygienist under the laws of

another state, who are in good standing, and who otherwise meet the

requirements of the Dental Health Care Act

The Dental Health Summit was viewed as an opportunity to continue the

momentum in New Mexico and provide another source of input to the legislative process in assuring access to dental health services for all New

Mexicans.

The first afternoon’s large group discussion proposed an intensive review

of five major areas—

1) Health promotion/disease prevention

2) Supply/demand

3) Access/infrastructure 

4) Education/training

5) Finance/Medicaid/insurance issues

Topic groups were charged with evaluating these issues and proposing recommended strategies.The strategies were presented the following afternoon and

approved by the general assembly.

Recommendations under the health promotion/health prevention category

included—

• Promoting an early childhood caries program that addresses prenatal

women and children age birth–3

• Encouraging innovative technology for prevention and treatment

• Promoting educational media campaigns 

Utah

• Initiated and facilitated a Medicaid

EPSDT and dental staff conference

call to discuss current state initiatives on dental care access, including a discussion of tentative plans

to hold a dental summit

Wyoming

• Initiated discussions with the

state dental director to identify

opportunities for a dental summit

Regional Initiatives

• Partnered with the Head Start

Quality Improvement Center to

provide Medicaid and SCHIP eligibility and benefit package presentations at five regional conferences for new Head Start

staff, identifying ways we can

work together to get more children served

• Instigated regional state dental

directors conference calls on a

quarterly basis to discuss the

oral health initiative and current

state activities.We also included

Nebraska from Region VII at

their request

• Provided presentations on the

oral health initiative to Primary

Care Association meetings 

National

• Participated in the RO/Central

Office meeting of the Oral Health

Initiative teams and the National

Oral Health Conference in Chicago

• Represented HCFA at the Head

Start/Women, Infants, and Children

Dental Initiative rollout conference

• Provided input in the development

of the national GIS mapping project,

participating in training of state staff

and evaluating data collection

methodologies and mapping 

strategies
Oral Health

26 Oral Health ▼ National Head Start Bulletin

• Mandating the fluoridation of community water 

These recommendations are viewed as necessary steps in

the elimination of inadequate dental health care for many

New Mexicans. A dental health coalition was created to

further promote Senate Joint Memorial 21 and to work to

address the recommendations of the workgroups. The

goals and recommendations identified by summit participants, if acted upon by the coalition, would go a great

distance toward assuring preventive and curative dental

health care for those in New Mexico who presently suffer

the consequences of inadequate dental health care.

Marilyn Smith is a Health Specialist, West Texas Cluster

Manager, Head Start QIC,Texas Tech University – Institute for

Child and Family Services, T: 800-527-2802; E: msmithrn@

worldnet.att.net.

Under the supply and demand category, recommendations included—

• Encouraging the legislature to pass legislation that encourages a dental scholarship program

• Supporting a tax credit or exemption as an incentive to dentists in rural areas

• Reinstating New Mexico’s National Health Service Act to promote a greater distribution of providers

• Encouraging states to publicize and promote “loan for service” programs

• Initiating a “Dental Career Ladder” supported through community colleges

• Establishing dental auxiliary programs through the dental board and the community

• Expanding the roles of dental assistants and hygienists

• Expanding Medicaid’s scope of practice to include participation in recruitment of dental personnel

The access/infrastructure category recommended—

• Encouraging partnerships between the private and public sector

• Educating the legislature to address oral health access and funding issues

• Promoting the use of alternative services such as mobile dental services

• Employing capital funds for school-based clinics, Medicaid outreach workers pay, and cost reimbursement for licensed

social workers

• Assessing current models and improving or duplicating where feasible

• Promoting media participation to educate people about the disparities in access

The education and training category developed the following recommendations—

• Integrating a dental educator into Welfare to Work efforts

• Expanding dental training programs including those for dental hygienist

• Educating the general population about the need for preventive and primary dental care 

• Encouraging collaboration among private and public sectors to support linkages between education, supply, access,

finance, and health promotion and disease prevention strategies

Recommendations from the financial category included—

• Looking into ways in which Medicaid could have independent dental contracts as opposed to contracting solely with

HMOs

• Encouraging the reduction of barriers within the payment system

• Advocating for pre-authorization to reduce the potential problem of dental denial

• Creating a current state administered database for dental providers, services, participants, and expenses
Oral Health

National Head Start Bulletin ▼ Oral Health 27

Toothbrushing and Head Start: 

What's It All About?

By Dr. Harry W. Bickel, Jr.

Since three- and four-year-old children

have trouble tying their shoes, how can

we expect them to brush their teeth in

the classroom?

Actually I have asked myself this

question many times. As a dentist,I think

all people should brush their teeth as

often as possible. I realize this is impossible in the fast-paced, modern world.As a

person who has spent a lot of time in

Head Start classrooms, I cannot ignore

the fact that classroom toothbrushing is

a difficult and time-consuming activity. It

is also a messy one.

Consequently, the question arises,

“Is it worth it?” I guess that is a matter of

personal opinion. If you value teeth,

health, and personal hygiene, then your

answer will be “yes". In my opinion classroom toothbrushing is worth it, but then

again, I am a dentist. Some of my reasons

may be different from yours.

For at least a century,dentists have

been telling their patients that if they

brush their teeth, they will not have

tooth decay. Parents and teachers, of

course, have been imparting these same

pearls of wisdom to their children. The

problem is, people still get decay, even if

they brush all of the time.Why is this?

The reality is that decay is the

result of several factors, toothbrushing

or oral hygiene being only one of them.

Other major factors are exposure to

fluoride, diet (particularly sugar intake),

and tooth morphology or structure. If

you do not have control of these factors, then the best toothbrushing in the

world may not prevent decay. It can,

however, help.

Looking at the larger picture

illustrates that reducing tooth decay is

only one of the possible benefits of

good oral hygiene. Without question,

there is also a direct relationship

between good oral hygiene and healthy

gums. Though most people do not

realize it, teeth are lost because of gum

disease as much as they are lost

because of tooth decay. Since gum disease does not affect children, we do not

usually think about it in Head Start.

However, the people who lose their

teeth to gum disease are usually the

ones who didn't learn to take care of

them as children.

Now, we are finally down to the

heart of the matter: It is most important to realize that we can do things for

children that will affect them for the

rest of their lives. This is what Head

Start is all about. This is what we are

trying to do by teaching them to brush

their teeth. Like so many of the things

we do in Head Start, this is simply part

of the process of giving children the

tools they will need in the future to be

happy, healthy, and productive adults.

One goal of classroom tooth

brushing in Head Start is to create a

desire in the children to have a clean

and healthy mouth.We do this by making toothbrushing a part of our daily

routine. In other words, we are trying

to develop a positive health habit. This

is no different than teaching children to

wash their hands or flush the toilet or

a number of other things that we teach

in Head Start. It is simply a different

behavior and a different result.

My advice to teachers, then, is to

focus on the experience and not the

technique.Technique will come later as

motor skills improve. For now, make it

a positive experience for the children.

Make them understand that this is also

something they should do at home

and continue doing after they leave

Head Start.

Now for some questions—

What about the mess? 

Do not worry about it. It is certainly

not as messy as finger-painting.

Will toothbrushing spread disease? 

Not if it is done properly.There should

be no more potential for spreading disease from toothbrushing than from

many other things we do in Head Start,

such as handling dishes or helping children use the bathroom or blow their

noses.The key here is to use your head

and realize that the bristles of the

brushes contain microorganisms, some

of which are capable of causing disease.

When you place the toothpaste on the

brush, make sure that the mouth of the

tube does not drag across the brush.

Better yet, put the toothpaste on a

small square of wax paper and then on

the brush.

What kind of toothpaste should I use? 

This really does not matter too much. I

would suggest using a toothpaste that is

approved by the American Dental

Association (ADA) since these have

been tested and approved. If it does not

have the ADA seal of approval, then you

really don't know its quality.
Oral Health

28 Oral Health ▼ National Head Start Bulletin

Should I use a fluoride toothpaste? 

Yes. Recent research has demonstrated

that the topical effect of fluoride

(directly on the surface of the teeth)

may be as great as the systemic effect

(via the bloodstream, as in community

water fluoridation). Many also recommend that the child not rinse after

brushing so that the fluoride will

remain on the teeth longer.

What kind of toothbrushes should

I use? 

Use a children's toothbrush (one with a

small head) that has soft bristles. If you

do not already have a ready source of

toothbrushes, check with one of your

local program dentists. He or she

should have a number of dental supply

catalogs from which you can order. If

you really want to get fancy, you can

have your program's name printed on

the handles.

What toothbrushing method should

I use? 

I would recommend that you have the

children use what is often referred to

as the “scrub brush method”. This simply means that you place the brush

against the teeth and move it in a circular motion. Make sure that the brush

goes up near the gum line where much

of the plaque is located. Also, do not

forget to brush the tops and the insides

(tongue side) of the teeth and not just

the front surfaces.

Should I use floss? 

Though some people may disagree, I

think three- and four-year-old children

should not attempt flossing, at least not

in a group setting. They simply do not

have the manual dexterity to do it.

How should I store the toothbrushes? 

This is probably the most frequently

asked question about toothbrushing.

Toothbrushes should be stored in the

most hygienic way possible. There are

many good ways to do so and people

need to decide what works best for their

particular situation. I do, however, think

that any toothbrush storage should meet

certain criteria. Here are the ones that I

would suggest:

1. Toothbrushes should be stored in a

manner that prevents cross-contamination. This is the basic principle that

determines whether or not our storage method is adequate. We do not

want to transmit one child's germs to

another via the toothbrush.

Consequently, toothbrushes must not

be allowed to touch one another and

must be returned to a proper storage

site each time they are used. Finally,

toothbrushes must be clearly labeled

with the child's name so that each

brush returns to the same mouth

each time.

2. Toothbrushes should be stored in a

manner that allows them to dry

properly. It is important, from a

microbiological standpoint, that

toothbrushes not be allowed to

remain moist during storage. The

optimum conditions for bacterial

growth are dark, warm and moist.

Most, but not all, bacteria do not survive well without a source of 

moisture. This means that wrapping

toothbrushes in plastic wrap, or placing them in a container that has no

ventilation, is not advisable.

3.Toothbrushes should be kept in individual containers or in a cabinet that

can be closed. Many of our Head

Start classrooms are in old buildings,

where insect control is either impossible or less than optimal.We do not

want to hear from Head Start staff

who go into their classrooms after

hours and find bugs crawling over the

toothbrushes!

4.Where possible, toothbrushes

should be stored with the bristle end

up. This keeps the bacteria that are

on the handle from running back

onto the bristles during storage.

Several different hands may have

touched the handle of the brush

while it was being used and the brush

was probably wet when returned to

the holder.

5.Storage containers should be either

washed in a dishwasher or sterilized

periodically. Over time, as individual

containers are used on a daily basis,

they tend to build up a lot of material

from the toothbrush. While most of

this is dried toothpaste, some of it

may not be.

One of the things I enjoy most when I

walk into a Head Start classroom is for

the children to run up to me and tell

me that they brush their teeth.They are

proud of it. They want to tell me that

they are doing it. This, in itself, should

illustrate why a commitment to brushing teeth is important.

Harry W. Bickel, Jr. D.M.D. is a Health

Specialist, Region IV Quality Improvement

Center,Western Kentucky University,T: 270-

745-4041; E: hbickel@home.com.
Oral Health

National Head Start Bulletin ▼ Oral Health 29

“Why bother? They’re just baby

teeth!” I cannot tell you how

many times I have heard that

statement over the past 30 years.

I do not usually hear it from the

parent of a child, because I have

limited contact with parents.Most

likely, I hear it secondhand, from a

health coordinator or family 

service worker. They, however,

have heard it repeatedly from parents. “Why bother? They’re just

baby teeth.The child is gonna lose

them anyway.”

My usual response to this question involves a detailed explanation of

the development of the teeth, accompanied by a series of poorly drawn

sketches (I am a dentist, not an artist).

My idea here is to provide people with

all the ammunition they will ever need

to counter these statements. This is a

dentist’s approach: use knowledge to

prove your point. While I feel that

teaching the consequences of untreated

disease is important, that is not what I

plan to do here. Instead, I will start at a

much more basic level and will begin

with a story.

Many years ago, when I was a

Head Start dental consultant for the

U.S. Public Health Service, I worked

with a program in the mountains of

Eastern Kentucky. Part of my work

involved visiting the centers and examining the children for evidence of dental treatment. I will never forget my

visit to one very rural center. As I

walked into the classroom and began

talking with the staff, one of the staff

members pointed to a little boy who

was sitting at a table playing quietly.The

staff member said that this child had

been their number one behavior 

problem from the very first day of

school. In fact, they had completed six

mental health referrals on the child, all

to no avail. Nothing worked until they

fixed the child's severely decayed teeth.

From that point on, the child behaved

like all the other children.

That small incident made an

indelible impression upon me. It caused

me to realize how much pain some of

these children experienced. Even

though I have had children come to me,

crying from the pain of a toothache, I

never understood until then how much

it affects their entire life, particularly if

it is allowed to drag on. I can not imagine children that small having to face

that much pain every day of their life.

I could continue describing all the

problems that might occur if we fail to

deal with a child’s dental problems. The

child can not eat properly.The child has

trouble speaking.The child has infections

that are draining into the mouth. The

child’s permanent teeth may come in

crooked or jumbled-up, because we have

lost the baby teeth too early. All of these

are valid reasons why we should deal

with dental problems. They are overshadowed, however, by one very important reason:the child may be in pain or,at

the very least, susceptible to pain.

Dentists may not know everything, but we do know one thing:

decayed teeth do not get better.What

looks like a small hole today could

become an extraction three months

from now. If teeth simply decayed and

disappeared, the consequences of nontreatment might be far less.

Unfortunately, however, this is not the

case. As decay worsens, the likelihood

of developing an abscess increases dramatically. An abscess is a serious infection that can spread throughout the jaw

and cause extreme pain.

If a child came to us with open sores, or

visible injuries, we would do something

about it immediately. Because it is in the

mouth, however, we often allow much

more serious conditions to persist.

Maybe it is because they are “baby

teeth” and they are going to be lost

anyway. Maybe it is because they are in

the mouth, and we do not have to look

at them as often.Whatever the reason,

ignoring the problem is not the right

thing to do. Pain is pain, regardless of

where it occurs in the body. If we in

Head Start are truly child health advocates, we need to make sure this pain is

dealt with properly and quickly.

Harry W. Bickel, Jr. D.M.D. is a Health

Specialist, Region IV Quality Improvement

Center,Western Kentucky University,T: 270-

745-4041; E: hbickel@home.com.

Why Bother? They’re Just Baby Teeth! 

By Dr. Harry W. Bickel, Jr.

Dr. Harry Bickel, Jr.
Oral Health

30 Oral Health ▼ National Head Start Bulletin

Fluoride Supplements: By Prescription Only! 

By Dr. Harry W. Bickel, Jr.

Over the past several years, I have

encountered a number of classrooms

where children were given fluoride

tablets or were brushing with a fluoride gel. In most of the cases, this was

being done either improperly or illegally

or both.

Fluoride is placed in many public

water supplies for the sole purpose of

preventing tooth decay. The amount is

so small (1 part per million) that it

causes no health problems, but it does

reduce the amount of decay. If you put

more fluoride in the water, you

would prevent even more

decay. However, you would also

run the risk of causing a very

mild form of teeth staining

called fluorosis or mottling.

In many areas of the county, particularly in rural ones, fluoride is not found in the water

supply (although fluoride may be

found naturally in well water). In

these areas, it is possible to provide fluoride to individuals in

other ways, namely through fluoride supplements. Supplements

which are ingested are called

systemic fluorides and usually

take the form of tablets and

drops.Those that are applied directly to

the teeth are called topical fluorides and

take the form of rinses, gels, varnishes,

toothpastes, and so forth. Some of these

are available over-the-counter and some

are available by prescription only.

Other than using a fluoride toothpaste, fluoride supplements should not

be administered in a Head Start classroom unless it is recommended and

supervised by a licensed dentist.

While the chances of causing a

problem with fluoride supplements are

minimal, it is far too complex a process

to be undertaken by a non-professional.

Before fluoride tablets or drops are

given, it is necessary to test the child’s

home water supply for fluoride and

interview the parents to determine if

there are any other possible sources of

fluoride. Dosage of fluoride tablets and

drops varies according to the age of the

child and the amount of other fluorides

available. Fluoride rinses are not intended for young children because children

tend to swallow them. Additionally,

many of the fluoride gels are not recommended for children under the age

of six.As I said, this is a complex issue.

Another serious problem is the

wide availability of fluoride supplements

without a prescription. Most of the fluoride supplements listed above are

legally available by prescription only.

Unfortunately, there are companies

that will sell them directly to schools

and Head Start programs, without the

involvement of a dentist.

I recently talked with a health

coordinator who was having the children brush once a week with a fluoride

gel. She had never talked to a dentist

about this, nor was one overseeing the

program. This was simply something

that they did when she got there. She

was not even sure if there was fluoride

in the local water supply. She was buying the gel directly from the catalog of

a nationally known distributor that sells

to most Head Start programs. I had her

send me a bottle of it and it clearly

states in large letters: CAUTION: FEDERAL U.S. LAW PROHIBITS DISPENSING WITHOUT PRESCRIPTION. If

there was a prescription involved, it

was certainly issued without the

knowledge of the program.

The most important issue in this

article is that fluoride supplements require the

expertise and input of a dentist before they are administered by a Head Start program. The type of supplement and the dosage must

be individualized to each

child and must be administered according to strict

protocols. Many state health

departments have supplemental fluoride programs in

rural areas and it is fine for

Head Start programs to participate in them. They are

overseen by dentists, adhere

to state and federal laws, and

use appropriate scientific principles. In

all other cases, a Head Start program

should enlist the help of a local dentist

(preferably one who is on the Health

Service Advisory Committee) and

make sure that what she or he is doing

is both proper and legal.

Harry W. Bickel, Jr. D.M.D. is a Health

Specialist, Region IV Quality Improvement

Center,Western Kentucky University,T: 270-

745-4041; E: hbickel@home.com.
Oral Health

National Head Start Bulletin ▼ Oral Health 31

When Michael was very young, he had health problems for

which a lot of antibiotics were prescribed. The antibiotics

contributed to severe tooth decay and when Michael

entered Head Start, he had still not received the necessary

treatment because his family was uninsured and not eligible

for Medicaid.

Because each child receives medical, vision, and dental

screenings upon entering the Community Partnership for

Child Development’s (CPCD) programs, Michael’s dental

concerns were identified and he was immediately referred

for treatment.CPCD partners with numerous dentists in our

community to provide services at reduced fees for children

in our programs. Small Smiles Dental Clinic provided Michael

with the necessary dental treatment and CPCD paid for the

bill out of funds raised in the community.Thanks to the support of organizations such as Pacificare Foundation, the

Colorado Springs Dental Society, Nutrition Camp School

Foundation, and Peterson Air Force Base Officers’ Wives

Club, CPCD is able to ensure that all of the children in our

programs receive the treatment they need, without regard to

their ability to pay.

As a result of prevention and early intervention health programs, children are healthier and more successful in school

and life. When Michael looked in the mirror the first time

after receiving treatment, he said, “Now the other children

won’t laugh at me anymore."

Michael’s mom is very pleased with the results.“Michael can’t

stop smiling now!” she said.“And his speech is a lot clearer.”

CPCD would like to thank Small Smiles Dental Clinic and the

numerous other dentists for their support of our programs.

This article was reprinted with permission from the CPCD

Community Connection, a quarterly publication of Community

Partnership for Child Development, Colorado Springs, Colorado,T:

719-635-1536; Web page: www.cpcdheadstart.org.

Something to Smile About

By Mary Skatberg
Oral Health

32 Oral Health ▼ National Head Start Bulletin

The Implication of Culture on Oral Health

Practices in Migrant Head Start Programs

By Tracy Finlayson 

Migrant Head Start families face many of the

same challenges that other low-income families living in isolated, rural areas face when

seeking health and oral care services. These

challenges include a lack of health care

providers who accept Medicaid, long waiting

times for appointments,and having to travel in

excess of 30 miles to obtain health and oral

health care services. However, Migrant Head

Start families face other challenges unique to

their population, such as lack of health insurance, mobility factors, language barriers, and

varying cultural beliefs.

Sandra Carton, Migrant Programs

Acting Branch Chief for the Head Start

Bureau, cites access to health services and

communication issues as primary concerns

among migrant families. Most migrant families

do not have Medicaid coverage, primarily due

to the lengthy eligibility process and the

mobility of migrant families. Also, families

coming from a country where medicine is

socialized may not understand the need to

obtain health care insurance while they are

residing in this country. Lack of insurance

inhibits a family’s ability to obtain health and

oral health services when they are needed.

If a health care provider does not speak

the same language as the family, then the trust

and responsiveness that is crucial to building a

strong relationship between the family and

health care provider cannot take place. In

many cases, translators are needed. This further complicates building a trusting relationship.Even if interpreters are not needed,there

is still no guarantee that the provider and

patient understand each other and have the

same ideas or beliefs about the course of

treatment. Other cultural differences in childrearing practices may also come into play and

affect treatment.

Cultural beliefs govern people’s values

and daily practices,and there are several areas

in oral health where cultural practices seem

Paul Blatt, Donald Wyatt, Sandra Carton, Migrant Programs Branch, Head Start Bureau
Oral Health

National Head Start Bulletin ▼ Oral Health 33

to conflict with the traditionally recommended courses of action promoted by

American health providers.An example of

this would be timing of weaning.

Oral Health Forum authors

Norman Tinanoff and Carol Palmer include

several nutritional recommendations to

help decrease the risk of dental caries in

young children. One of the practices they

encourage is weaning at the appropriate

time, which most pediatricians agree to be

around one year of age. However, this

practice is not universally accepted by all

cultures. For instance, Hispanic communities have a cultural value of dependence on

family and would not be eager to practice

a pediatrician’s recommendation for early

weaning or toilet training, as this would

promote independence of the baby from

the family.

For recommendations to become

integrated into daily routines, the medical

evidence and reasoning must be clearly

expressed to the family.Telling a parent to

do something contrary to their cultural

beliefs without explanation is not an

effective way to get someone to change

health behaviors. Often, there is no way of 

knowing what recommendations health

providers in other countries may have

made to a family. According to Sandra

Carton, “Health providers should be

bicultural, not just bilingual.” 

Migrant Head Start Programs are

the bridge between the family and health

care providers, and depend on the trust

and rapport they have developed with the

family. As Sandra Carton points out,“They

don’t do just what is required, they do

what is needed to work with families—

with less time than most Head Start programs." Often this translates into meetings

with families during evenings or weekends,

or more home visits. Migrant Head Start

programs serve as advocates for children by

establishing collaborative relationships

with health care

providers to

increase their

sensitivity to

cultural differences and

other barriers

migrant families often face.

During the

regional breakout

session of the Oral

Health Forum, these

and other issues affecting

Migrant Head Start families

were discussed. Several action steps were

identified, including educating staff and

parents in their own languages about current trends and changes to Medicaid and

SCHIP; building relationships with dentists

so they will accept children referred from

Migrant Head Start programs; developing a

list of key points that staff can discuss

when making contact with health care

providers; and building and expanding contacts with local community and migrant

health centers to obtain information about

available services.

Participants in the breakout session

summarized their approach with this tag

line: “Champions in partnerships: challenging the dental and medical professionals and Head Start in meeting the needs of

infants, toddlers, and preschool children,

especially migrants, homeless, and other

populations.” 

Tracy Finlayson was an Intern, Head 

Start Bureau.

Tracy Finlayson,

Head Start Bureau Intern
Oral Health

34 Oral Health ▼ National Head Start Bulletin

Access to oral health care is a major

issue that continues to challenge staff in

Indian Head Start Programs nationwide. At the Oral Health Forum, participants from different areas of the

United States and different perspectives came together to identify barriers

to access and develop action plans to

fix the problem. Participants “spoke

from the heart and echoed each other,”

according to W. J. Strickland, Head Start

Bureau’s Indian Branch Program

Specialist.Although there were no

identified cultural barriers, participants saw many universal problems affecting all Indian families.

A large problem is a lack of

training and consistent information available to staff, dental care providers, and

parents. Overall, programs reported

feeling isolated, and unable to provide

access to oral health care or preventive

practice training and education.There is

a lack of knowledge available to individual American Indian Head Start programs about the level of water fluoridation in their communities. This impairs

their ability to assess whether children

need fluoride supplements.The need to

gain support for screening and follow-up

efforts was also discussed and participants suggested that one way to address

the issues of isolation would be for

American Indian Programs Branch

(AIPB) grantees to form coalitions. The

coalition could start a dialogue with

local dental hygiene schools, since they

exist in almost all the states and can

become involved with the Indian Head

Start programs.Participants also felt that

the needed information and support

could come from the T/TA networks.

T/TA providers could increase the training and up-to-date information sessions

they offer to educate parents and staff.

For some families that are able to

access care and schedule an appointment, there remains the issue of following through and keeping their

appointments. Lack of transportation

sometimes arises as another barrier to

accessing care. Also, while Head Start

children have Medicaid to cover the

cost of dental treatments, too few dentists accept this form of payment. The

dentists who do accept Medicaid and

work with Head Start children need to

be better recognized and appreciated

by programs.

Indian Head Start programs are

the link to continuing strong relationships between Head Start children and

dental providers in their communities.At

the Oral Health Forum, the following

strategies for action to increase oral

health care access were also discussed—

• Encourage oral health care providers

and dentists to become members of

the Health Services Advisory

Committee (HSAC)

• Encourage parents to take children

to dentists by age one

• Obtain information about foundations that might support improved

dental health

• Obtain information about Title V services and support for dental health

• Ask for federal support to encourage

people to become involved in pediatric

dentistry

• Offer more frequent screenings of

children, and screen mothers

• Offer updated training materials to

WIC, nutritionists, parents, and AIPB

staff

• Include all key players in discussions,

work holistically,and get together with

partners to develop timelines and

plans

Identify and implement prevention strategies such as gum swabbing, good nutrition, and tooth

brushing

• Ask the Quality Improvement Centers

(QICs) to develop tip sheets and other

educational information

These action plan ideas were generated

from the participants representing the

Indian Head Start programs. Participants

had a positive experience and left the

Forum with a “glimmer of hope that

there would be action on the horizon,”

says W. J. Strickland. He expressed the

importance of their input and emphasized that the “next time the Head Start

Bureau has a forum, people [should] be

encouraged to attend and have their

voices heard.We have a commitment to

the programs to work in partnership.”

The Oral Health Forum provided an

occasion to share ideas and experiences.

It created a great deal of enthusiasm for

addressing oral health issues and making

positive changes in Indian Head Start

Programs. The message is clear in their

slogan: “Beautiful smiles for wholeness

and wellness in the new millennium.” 

Tracy Finlayson was an Intern, Head Start

Bureau

Oral Health Care Access Issues for Head Start’s

Indian Programs

By Tracy Finlayson

“Beautiful smiles for wholeness and

wellness in the new millennium.” 

Munel Richardson and W.J. Strickland,American Indian Programs

Branch, Head Start Bureau

•
National Head Start Bulletin ▼ Oral Health 35

Dental Coverage

Under Medicaid

Medicaid—the largest program providing medical and

health-related services to eligible needy persons in the

U.S.—is a means-tested entitlement program jointly

financed by federal and state governments and administered

by the states. Medicaid provides health and long-term coverage, including dental, for eligible individuals and families

with low incomes and resources. In 1998, 41.3 million people received Medicaid services. Of those:

• 21.3 million were children;

• 9.2 million were adults;

• 4.1 million were elderly persons; and 

• 6.7 million were blind and disabled persons.

Who Has Dental Coverage Through

Medicaid?

The EPSDT (Early Periodic Screening, Diagnosis, and

Treatment) benefit requires states to provide all Medicaideligible children under the age of 21 with comprehensive,

preventive, restorative and emergency dental services furnished according to state-defined periodicity schedules. In

1996, 22.9 million children were eligible for EPSDT.

However, the percent of children receiving preventive care

through EPSDT remains low.

Most states have failed to meet Medicaid’s mandate

that all children receive early preventive care through the

EPSDT benefit.

States may choose whether or not to provide adults

with dental services.These states also have the flexibility to

determine the number of adults they choose to cover and

the type and amount of services they choose to provide.

Most states cover emergency services but fewer states

cover preventative, restorative or more complex services

for adults.

• About 6 million,or 18%,of all Medicaid recipients receive

dental services (average between 1994 and 1996).

• Children aged 14 years and younger accounted for an

average of 62% of Medicaid-insured patients treated at

dental practices.

• In 1996, 18% of eligible children received any EPSDT

required preventative dental screening or services.

What About Medicaid and CHIP?

With the introduction of the State Children’s Health

Insurance Program (CHIP), states have the opportunity to

expand coverage through the expansion of existing

Medicaid plans,through the adoption of a non-Medicaid plan

or some combination of both. States choosing to expand

existing Medicaid plans must provide standard Medicaid

dental benefits for children.

Inclusion of Dental Services in State 

CHIP or Medicaid Expansion Plans

Dental services included through CHIP

Dental services included through Medicaid expansion

No dental services offered through CHIP

To be included in pending CHIP plan

* Dental services in Florida my be covered at each county’s

option.

Source: National Conference of State Legislatures,August 1999
36 Oral Health ▼ National Head Start Bulletin

What About Medicaid and Managed Care?

Under managed care, Medicaid agencies may provide dental

services through one of three options:

1.Comprehensive managed care organizations (MCOs) that

deliver both medical and dental services.

2.MCOs that deliver only dental services.

3.Fee-for-service programs.

Managed care provides states an opportunity to

improve access to care. By monitoring access to providers

and health plans and ensuring consumer satisfaction, managed care organizations can provide useful information for

improving access and utilization.

Innovative policies may also help to insure the provision and sustainability of oral health services as a component of managed care. For example, provision of sealants

through school-based health clinics is one way that some

managed care organizations are implementing guidelines for

providing sealants and requirements for providing outreach

to communities.

The majority of low-income individuals, whether covered by Medicaid or private insurance, receive dental services in the private sector. As more Medicaid enrollees

receive care in the private sector through Medicaid managed care initiatives, it will be increasingly important to

ensure that private health care services meet the health

care needs of low-income individuals.

Enrollment and Utilization of Services by

Medicaid Eligible Persons

Continued efforts to improve enrollment for Medicaid

and use of dental services are important for three reasons.

First, there is poor dental provider participation in

Medicaid. Insufficient dental provider participation contributes to low enrollment and utilization of dental services by Medicaid beneficiaries. The high administrative

burden associated with voluminous paperwork and claims

processing is another barrier to dental provider participation in Medicaid. Numerous studies have identified low

dental reimbursement rates as a major reason for the lack

of dental provider participation. Medicaid reimbursement

varies by state.

Second, complicated enrollment processes and burdensome eligibility verification processes discourage

enrollment and utilization of dental services by Medicaid

beneficiaries.

Third, Medicaid beneficiaries place low prioritization on obtaining dental services, particularly preventive

care. In 1993, a 50-state study of children and their use of

preventive dental services by the DHHS Office of

Inspector General revealed that none of the states provided preventive dental services to more than 50% of eligible children. In addition, three-quarters of the states

provided services to less than 30% of eligible children.

Fourth, Medicaid beneficiaries lack information concerning the benefits of dental services. Nearly a quarter of

Medicaid-eligible adults do not know that dental care is provided through Medicaid.

Policy Recommendations

Increase enrollment and utilization

• Simplify enrollment processes.

• Use local public health agencies to provide care 

coordination.

• Educate beneficiaries about dental services.

• Broaden eligibility criteria for dental services.

Increase provider participation

• Establish competitive reimbursements for dental services.

• Insure timely payment to providers.

• Institute a loan forgiveness/repayment program for

providers who participate in Medicaid.

• Provide a higher match rate for Medicaid dental services

and for all children’s services.

• Create tax incentives for providers of dental services to

Medicaid recipients.

• Increase the number of specialists (e.g.,orthodontists) eligible for reimbursement under state Medicaid programs.

Simplify administrative processes

• Make CHIP administrative processes similar or identical

to Medicaid processes to streamline effectiveness.

• Use standard claim forms and eliminate inconsistencies in

federal requirements so that Medicaid claims processing

is similar to that of private insurance companies.

• Increase federal and state monitoring and enforcement of

EPSDT.

• Clarify Medicaid rules and regulations.

• Ensure that managed care contracts specify dental 

provisions.

• Adapt standard American Dental Association forms and

codes.

• Reduce or eliminate prior authorization.

References

1.Spisak S, Holt K, eds. 1999. Building Partnerships to Improve

Children’s Access to Medicaid Oral Health Services: National

Conference Proceedings.Arlington,VA: National Center for

Education in Maternal and Child Health.

2. Isman R, Isman B. 1997. Access to Oral Health Services in

the U.S. 1997 and Beyond. Chicago, IL: Oral Health

America.

3.American Dental Association. 1998. 1998 Survey of State

Dental Programs in Medicaid. Chicago, IL:American Dental

Association.

4. Kaiser Commission, 1998. The Medicaid Program at a

Glance.Washington, DC: Kaiser Commission.

Reprinted with permission from The Center for Policy Alternatives • 1875 Connecticut Ave., NW, Suite 710 • Washington, D.C. 20009 • (202) 986-2539 • www.stateaction.org
Oral Health

37 Oral Health ▼ National Head Start Bulletin

At a recent health conference in Washington D.C.,

the U.S. Surgeon General emphasized the importance of good oral care in the overall development of

children. Nowhere is this better understood than

through the long-term partnership of Head Start and

the Colgate-Palmolive Company. Since 1991, Colgate

and Head Start have worked together to educate

children and their families about the importance of

good oral care through the award-winning Colgate

Bright Smiles, Bright Futures program. Each year, this

multimedia classroom kit brings developmentally

appropriate, self-esteem-based materials and activities into Head Start centers nationwide.

Now, for 2001, Colgate is extending its commitment

to include an all-new, free program kit for Early

Head Start. This new addition to the Bright Smiles,

Bright Futures family of education materials focuses

on the importance of good oral health from before

birth through the age of 24 months. Because it

is a fact: good oral health practices during these first

two years of a child’s development are critical in

helping his or her smile to last a lifetime.

Classroom kits are available to Early Head

Start programs through their grantee on a

first-come, first-served basis, and include a

Teachers Guide, poster, and a set of four reproducible Parent Take-Homes. Orders will be fulfilled upon request of the grantee—so be sure

to contact your grantee to obtain your copy of

Colgate Bright Smiles, Bright Futures for Early

Head Start!

Bright Smiles, Bright Futures:

New Oral Health Kit for Early Head Start

Tufts University School of Dental

Medicine is producing a video on 

oral health that will be available for 

distribution in the spring of 2001.

For more information about the 

video, please contact—

Carole Palmer Ed.D., R.D.

Tufts University School of Dental

Medicine

1 Kneeland Street

Boston, Ma 02111.

e-mail: carole.palmer@tufts.edu.
38 Oral Health ▼ National Head Start Bulletin

REGION I 

(CT, ME, MA, NH, RI,VT)

Barbara Tausey, MD, MHA

Regional Consultant for Oral Health

PHS Region I,

JFK Federal Building,

Room 1826

Boston, MA 02203

Telephone: 617-565-1426

Fax: 617-565-4027

Email: btausey@hrsa.gov

Robin Lawrence, DDS, MPH

Oral Health Consultant

Lawrence Associates

Cohasset, MA 02025-1421

Telephone: 781-383-6776

Fax: 781-383-6776

Email: rlawrence@dreamcom.net

REGION II 

(NJ, NY, PR,VI)

Jan Richard Goldsmith, DMD, MPH

Regional Dental Consultant

DHHS/HRSA/BPHC/DHSD, Region II

26 Federal Plaza, Suite 3337

New York, NY 10278

Telephone: 212-264-2768

Fax: 212-264-4497

Email: jgoldsmith@hrsa.gov

REGION III 

(DC, DE, PA,VA,WV)

Victor Alos, DMD, MPH

Regional MCH Dental Consultant

DHHS/HRSA/BPHC/MCH, Region III

Public Lender Building

150 S. Independence Mall West,

Suite 1172

Philadelphia, PA 19106-3499*

(*9 digit zip required)

Telephone: 215-861-4379

Fax: 215-861-4338

Email: valos@hrsa.gov

Melvin Lerner, DDS

Acting Director, OPMD

DHHS/HRSA/BPHC, Region III

Public Lender Building

150 S. Independence Mall West,

Suite 1172

Philadelphia, PA 19106-3499*

(*9 digit zip required)

Telephone: 215-861-4393

Fax: 215-861-4385

Email: mlerner@hrsa.gov

REGION IV (AL, GA, KY, MS,

NC, SC,TN)

Jim Friday, DMD

RPC, NHSC

HRSA Southeast Field Office

Atlanta Federal Center

60 Forsyth Street, S.W., Suite 3M60

Atlanta, GA 30303-8909

Telephone: 404-562-4170

Fax: 404-562-4108

Email: jfriday@phsatl.dhhs.gov

Galo Torres, DDS

Regional Migrant Dental Consultant

HRSA Southeast Field Office

Atlanta Federal Center

60 Forsyth Street, S.W., Suite 3M60

Atlanta, GA 30303-8909

Telephone: 404-562-4121

Fax: 404-562-4108

Email: gtorres@hrsa.gov

REGION V 

(IL, IN, MI, MN, OH,WI)

Robert S. Enders, DDS

Regional Clinical Coordinator

Chicago Field Office

105 West Adams Street, 17th Floor

Chicago, IL 60603

Telephone: 312-353-1658

Fax: 312-353-3173

Email: senders@hrsa.gov

REGION VI 

(AR, LA, NM, OK,TX)

Robert A. Sappington, DMD, MPH

Regional Dental Clinical Coordinator

DHHS/HRSA 4, 10th Floor

West Central Field Office

1301 Young Street

Dallas,TX 75202

Telephone: 214-767-3719

Fax: 214-767-8049

Email: rsappington@hrsa.gov

Carol Sherman, DDS,MPH

Regional Clinical Consultant

DHHS/HRSA 4, 10th Floor

West Central Field Office

1301 Young Street

Dallas,TX 75202

Telephone: 214-767-3719

Fax: 214-767-8049

Email: csherman@hrsa.dhhs.gov

REGION VII 

(IA, KS, MO, NE)

Lawrence W.Walker, DDS, MPH

Regional Dental Consultant

DHHS/HRSA/BPHC/DHSD, Region VII

601 E. 12th Street, Room 501

Kansas City, MO 64106

Telephone: 816-426-5226

Fax: 816-426-3633

Email: lwalker@hrsa.gov

Steven P. Geiermann, DDS

Program Management Officer/NHSC

DHHS/HRSA/BPHC/NHSC, Region VII

601 E. 12th Street, Room 501

Kansas City, MO 64106

Telephone: 816-426-2916

Fax: 816-426-3633

Email: sgeiermann@hrsa.gov

REGION VIII (CO, MT, ND,

SD, UT,WY)

James Sutherland, DDS, MPH

Regional Dental Consultant

DHHS/HRSA/BPHC/DHSD, Region VIII

1961 Stout Street, 4th Floor

Denver, CO 80294

Telephone: 303-844-3206

Fax: 303-844-0002

Email: jsutherland@hrsa.gov

REGION IX 

(AZ, CA, HI, NV, GU,TT)

Reginald Louie, DDS, MPH

Regional Dental Consultant

DHHS/HRSA/MCHB, Region IX

50 United Nations Plaza, Room 317

San Francisco, CA 94102

Telephone: 415-437-8101

Fax: 415-437-8105

Email: rlouie@hrsa.gov

John S. Betz, D.D.S.

Dental Director

Mariposa Community Health Center

1852 N. Mastick Way

Nogales,AZ 85621

Telephone: (520) 281-1550

Voicemail: (520) 761-2133, ext. 218

Fax: (520) 281-1112

Email: medicalstaff@theriver.com

REGION X 

(AK, ID, OR,WA)

Forrest Peebles, DDS

Regional Dental Consultant

DHHS/HRSA/BPHC/DHSD, Region X

2201 6th Avenue, MS RX-23

Seattle,WA 98121

Telephone: 206-615-2493

Fax: 206-615-2500

Email: fpeebles@hrsa.gov

HRSA FIELD OFFICE DENTAL CONSULTANTS

Region I, Boston

Peter B. Geller

80 High Street

Medford, MA 02155

Phone: (781) 391-8300

Fax: (781) 391-0776

Email: geller_p@a1.tch.harvard.edu

Region II, New York

Martin J. Davis

Columbia University

Division of Pediatric Dentistry

630 W. 168th Street

New York, NY 10032

Phone: (212) 305-3890

Fax: (212) 305-1034

Email: mjd2@columbia.edu

Region III, Philadelphia

Ross M.Wezmar

201 Jefferson Avenue

Scranton, PA 18503

Phone: (717) 346-7760

Fax: (717) 346-9002

Email: pedormw@aol.com

Region IV,Atlanta

James C. Beall

1243 Savannah Highway

Charleston, SC 29407

Phone: (843) 571-5644

Fax: (843) 571-5647

Email: jbeall@internet.net

Region V, Chicago

Charles S. Czerepak

2536 N. Lincoln Avenue

Chicago, IL 60614

Phone: (773) 880-5455

Fax: (773) 880-5809

Email: pinedent@aol.com

Region VI, Dallas

William D. Steinhauer

706 S.W. 24th Street, #103

San Antonio,TX 78207

Phone: (210) 432-1510

Fax: (210) 431-8611

Email: necd@texas.net

Region VII, Kansas City

Paul B. Kittle, Jr.

309 S. 2nd Street

Leavenworth, KS 66048

Phone: (913) 651-9800

Fax: (913) 651-8559

Email: pedident@aol.com

Region VIII, Denver

William A. Mueller

The Children's Hospital

Department of Dentistry, B240

1056 E. 19th Avenue

Denver, CO 80218

Phone: (303) 861-6788

Fax: (303) 837-2809

Email: mueller.william@tchden.org

Region IX, San Francisco

Richard S. Sobel

2901 Lone Tree Way

Antioch, CA 94509

Phone: (925) 757-4220

Fax: (925) 757-5457

Email: sobelrl@aol.com

Region X, Seattle

Bryan J.Williams

Children's Hospital & Medical Center

Department of Dental Medicine

4800 Sand Point Way, N.E.

Seattle,WA 98105

Phone: (206) 526-2243

Fax: (206) 527-3891

Email: bwilli@chmc.org

PEDIATRIC DENTAL CONSULTANTS
Oral Health

National Head Start Bulletin ▼ Oral Health 39

Resources

WIC and Head Start: Partners

in Promoting Health and

Nutrition for Young Children

and Families This is a recently published handbook developed by the

Food and Nutrition Service of the

U.S. Department of Agriculture and

the Head Start Bureau. This report

provides information on how WIC

and Head Start programs can work

together to enhance the quality of the health and nutrition

services provided to children and families. It describes the

successes, challenges, and lessons learned by state and local

WIC and Head Start programs who are already collaborating, and serves as a reference for those considering building

new collaborations or enhancing existing partnerships. To

download this on-line publication, go to

http://www.fns.usda.gov/oane/menu/published/wic/wic.htm.

A Healthy Mouth for Your Baby

This easy-to-read booklet is available

free of charge from the National

Institute of Dental and Craniofacial

Research. The booklet highlights the

importance of fluoride, cleaning your

baby’s teeth, preventing baby bottle

tooth decay, and taking your child to

the dentist. A Spanish version is also

available. For copies, contact the

National Institute of Dental and

Craniofacial Research, 45 Center Drive,

MSC 6400, Building 45/Room 4AS-19, Attn: Department Head

Start, Bethesda, MD 20892-6400.

Healthy Young Children: A

Manual for Programs–1995

Edition Reviewed by both health

and early childhood professionals,

this basic manual is used by early

childhood programs to promote

the health and safety of children,

staff, and families. Designed in a

readily usable format for ease in

locating information, it is frequently

used as a textbook.To order, contact

NAEYC at: 202-232-8777 (ext. 604), or visit their Web site at

www.naeyc.org.The cost of this publication is $16.00.

Books from the National Maternal and Child

Health Clearinghouse:

Oral Disease: A Crisis Among

Children of Poverty This fact

sheet discusses how preventable

oral diseases are still affecting a

majority of the children in

America, especially children of

poverty.

Early Childhood Caries

Resource Guide The Resource

Guide gives lists of useful

resources related to oral health,

including journal articles and

state, federal, and professional

organizations.

Crisis in Care: The Facts

Behind Children’s Lack of

Access to Medicaid Dental

Care This policy brief lists the

facts behind a lack of access to

Medicaid dental care and actions

that need to be taken.

Print copies may be ordered from the National Maternal and

Child Health Clearinghouse at 888-434-4624, or visit their Web

site at: www.nmchc.org.
Oral Health

40 Oral Health ▼ National Head Start Bulletin

ADA ONLINE, THE AMERICAN DENTAL 

ASSOCIATION

http://www.ada.org

Offers a comprehensive resource for oral health information

and education. The ADA is the professional association of

dentists dedicated to serving both the public and the profession of dentistry. Go to their parents and children section

for the following:

ADA Kids' Corner, Parents' Page, National Children's Dental

Health Month, Preventing Baby Bottle Tooth Decay.

The teacher and students section lists classroom activities,

links to free materials, and online ordering capability.

THE AMERICAN ACADEMY OF PEDIATRIC 

DENTISTRY 

http://www.aapd.org/

Dedicated to improving and maintaining the oral health of

infants, children, adolescents, and persons with special health

care needs. In addition to a wide range of information for

professionals and the public, they offer online brochures for

parents’ questions about children's oral health covering 24

different topic areas.

THE AMERICAN DENTAL HYGIENISTS 

ASSOCIATION

http://www.adha.org/

Includes a feature for kids, called Kids Stuff, with general

information, a game, and a chance to win a toothbrush. Also

has an E-mail address to direct questions to a hygienist.

NATIONAL INSTITUTE OF DENTAL AND

CRANIOFACIAL RESEARCH (NIDCR)

http://www.nidcr.nih.gov

Part of the National Institutes of Health, the mission of the

NIDCR is to promote the general health of the American

people by improving their oral,dental,and craniofacial health.

This site includes general oral health and patient care information and resources, research activities, programs, and links

to other related sources. Publishes brochures, articles, and

posters you can order or download. Topics focus on children's oral health issues: tooth brushing, nutrition, sealants,

and fluoride use. Offers several titles in Spanish as well.

THE NATIONAL ORAL HEALTH INFORMATION

CLEARINGHOUSE (NOHIC)

http://www.nohic.nidcr.nih.gov/welcome.html

A service of the National Institute of Dental and Craniofacial

Research. Many Americans have medical or disabling conditions that compromise oral health. NOHIC is a resource for

health professionals and these special care patients that

gathers and disseminates information from many sources,

including voluntary health organizations, research institutions, government agencies, and industry. NOHIC produces

and distributes patient and professional education materials,

including fact sheets, brochures, and information packets.

They also sponsor the Oral Health Database, which includes

bibliographic citations, abstracts, and availability information

for a wide variety of print and audiovisual materials. NOHIC

staff provides free custom or standard searches on specific

special care topics in oral health.

ORAL HEALTH AMERICA

http://www.oralhealthamerica.com

A fully independent, non-profit, national charity, working for

more than forty years to educate the public, improve access

to services, and support research and dental education.

Several informative articles and reports designed to raise

public awareness about oral health care disparities can be

obtained online here.

INDIAN HEALTH SERVICE ORAL 

HEALTH INITIATIVE

http://www.ihs.gov/publicinfo/publicaffairs/director/initiatives/oral2001jan.asp

The catalog of materials offers several good resources relating

to children's oral health. You can view their newsletter, Baby

Steps, the IHS policy on dental sealants, and information about

their Early Childhood Cavities (EEC) initiatives, including a

screening form that can be used for Head Start programs.

SURGEON GENERAL'S REPORT ON ORAL

HEALTH 

http://www.nidcr.nih.gov/sgr/oralhealth.htm

Site includes the recent press release in English and Spanish

and the complete report and executive summary in English.

For a more comprehensive listing of oral health Web sites, visit

Head Start Information and Publication Center at:

www.headstartinfo.org.

Oral Health and Children 

Virtual Resource Guide
Bureau Update

National Head Start Bulletin ▼ Oral Health 41

2000-2001 National Head Start Fellows

Beverly Ann Angustain is

an Even Start Director at

Plaza de la Raza Head Start

in the city of Commerce,

California. Beverly Ann’s

responsibilities include the

management and operations of the Even Start

Literacy Program. Before

this appointment, Beverly

Ann was Parent Educator at

Plaza de la Raza, Inc. She

earned a BA in American

Studies from California

State University, Los

Angeles, and has completed

graduate coursework in the Marriage, Family and Child

Counseling Program at Pacific Oaks College in Pasadena,

California. Beverly Ann’s voluntary activities include a variety

of local grassroots initiatives. She is an advocate of family literacy and a firm supporter of "Home, School, and

Community" collaborations and partnerships. Beverly Ann

will work with the Program Management and Operations

Branch in the Head Start Bureau, and can be reached at (202)

205-8899, or by E-mail at: bangustain@acf.dhhs.gov.

Terra Bonds is a Child/Family Development Specialist at

KCMC Child Development Corporation in Kansas City,

Missouri. She is responsible for working with children and

families in their home environments by providing parents

with education, employment, and housing resources, and

assisting families with developing strategies for building

strong foundations for their children. Terra earned an MS

degree in Counseling Psychology from Avila College in

Kansas City, Missouri, and a

BA in Psychology from

Spelman College, Atlanta,

Georgia. She serves as a

classroom leader for elementary school-aged children at

J.S. Chick African Centered

School and as an instructor

and public speaking trainer

for adolescents at the Kansas

City Media Project and

Leadership Institute. Terra

will work with the Family and

Community Partnerships

Branch in Head Start Bureau,

and can be reached at (202)

205-8034, or by E-mail at: tbonds@acf.dhhs.gov.

Harold “Jess” Brien is a

social worker for the

Division of Child Family

Service in Salt Lake City,

Utah. Jess was previously

employed as a child welfare

worker intern for the state

of Utah, a partial care 

worker, and director of personnel for the Crow Tribe

Administration, Crow

Agency, Montana. He

earned a MSW degree from

the University of Utah in

Salt Lake City and a BS in

Human Services from

Head Start has served as a national laboratory for services

to young children and their families, developing new knowledge to inform the entire early childhood field on best practices for young children. In keeping with this tradition, the

National Head Start Fellows Program was created.The core

of the program is an intensive work experience in

Washington, D.C.The Fellows spend one year working in the

administrative branch of the federal government where they

learn firsthand from nationally recognized leaders and contribute their knowledge, skills, and local perspectives to the

discussion of significant issues affecting children and families.

Head Start Fellows are energetic professionals who serve as

apprentices in the areas of program development, research,

child development, health, family development, and policy.

They also participate in educational and leadership development programs, attend seminars, and explore national issues

with senior government officials, policy makers, researchers,

community leaders, and innovative early childhood program

practitioners. We are proud to introduce the 2000-2001

Class of National Head Start Fellows:
Bureau Update

42 Oral Health ▼ National Head Start Bulletin

Montana State University in Billings, Montana. Jess’ voluntary

activities include providing recreational activities for members of the Salt Lake City Track Club and service as a consultant for the Indian Walk-In Center—Health Advisory

Committee. Jess will work with the American Indian Program

Branch, Head Start Bureau. He can be reached at (202) 205-

8696, or by E-mail at: jbrien@acf.dhhs.gov.

Beverly Gould is a doctoral

candidate at the New York

University School of

Psychology with a focus on

child and adolescent psychiatry. Prior to pursuing a Ph.D.,

Beverly was a clinical supervisor at an Early Head Start

program in New York, a clinician, social worker, and social

psychologist. Her community

service includes the co-development of a summer program

for neighborhood youth at

the Madala Center and membership in an Interfaith

Fellowship Choir. Beverly will work with the Health and

Disabilities Branch of the Head Start Bureau. She can be

reached at (202) 205-8478, or by E-mail at:

bgould@acf.dhhs.gov.

Traci Hefner was a Social

Service Manager for the New

Britain Head Start Program

in New Britain, Connecticut.

She was responsible for

ensuring that family advocates received appropriate

training and were familiar

with community resources.

She was also previously

employed as a behavioral

health care consultant for

Inglewood Associates in

Pittsburgh, Pennsylvania, and

supervisor at Summit Center

for Human Development in

Clarksburg,West Virginia.Traci earned an MSW degree from

West Virginia University in Morgantown, and a BA in Liberal

Arts from Fairmont State College, Fairmont, West Virginia.

She served as a Court Appointed Special Advocate in

Morgantown,West Virginia, and as a volunteer counselor for

the Sexual Assault Crisis Service in New Britain,

Connecticut. Traci will work with the Training and Technical

Assistance Branch, Head Start Bureau. She can be reached at

(202) 205-5931, or by E-mail at: thefner@acf.dhhs.gov.

Karen Heying is Executive

Director of Child Care

Choices, Inc. in St. Cloud,

Minnesota, a private nonprofit organization providing

child care resource and

referral and a child and adult

care food program. She was

previously employed as a

statewide consultant/director in Rochester, Minnesota,

for the Minnesota Child

Care Resource and Referral

Network and executive

director and national field

manager for Big Brothers/Big

Sisters of America. Karen’s voluntary activities include service

as a CanSurmount Coordinator for the American Cancer

Society and as a Big Sister for Big Brothers/Big Sisters of St.

Cloud, Minnesota. Karen will work with the Program

Operations Division of the Child Care Bureau. She can be

reached at (202) 205-8713, or by E-mail at:

kheying@acf.dhhs.gov.

Sarah Merrill was a

teacher at the John Hancock

Child Care Center in

Boston, Massachusetts. Her

responsibilities included the

implementation of care programs for seven infants, ranging in age from two months

to twenty months. Sarah also

has been a mentor teacher

for the past few years, working with protégé teachers

and assisting with their professional development. Her

voluntary activities have
Bureau Update

National Head Start Bulletin ▼ Oral Health 43

included serving as co-founder of the Wheelock College

Policy Seminar Advocacy for Care and Education Team,

founder of the John Hancock Child Care Center Sign

Language Task Force Committee, and service on the St. John’s

Episcopal Church Nursery Program Committee. Sarah will

work with the Early Head Start Team, Head Start Bureau. She

can be reached at (202) 205-8654, or by E-mail at:

smerrill@acf.dhhs.gov.

Dr. Guylaine L. Richard is

Director/Program Services

Coordinator for Family

Services Agency, Inc./Early

Head Start in Gaithersburg,

Maryland. Her duties include

the management, supervision,

and monitoring of the program’s staff and independent

consultants. Guylaine has also

been a consultant for the

Commonwealth of Virginia

Department of Social

Services, Professor of Allied

Health at Maryland’s Prince

George’s County Community

College, and Health/Mental Health/Nutrition Coordinator

for the Prince George’s County Public Schools Project Head

Start. She earned a Masters degree in Public Health from

George Washington University, an M.D. from Universite

d’Etat d’Haiti, and a Baccalaureate I and II from Institution

Ste. Rose de Lima, Port-au-Prince, Haiti. Her voluntary and

community involvement includes providing transportation

and assistance to elderly individuals through the American

Red Cross, conducting program activities for St. John’s

Literacy Institution at Prospect Hall in Frederick, Maryland,

and teaching religious education to youths at Mother Seton

Parish in Germantown, Maryland. Guylaine will work with

the Health and Disabilities Branch, Head Start Bureau. She

can be reached at (202) 205-8283, or by E-mail at:

grichard@acf.dhhs.gov.

Kathleen Sullivan is a Family Support Coordinator for

WSEM-CDC Head Start in Cleveland, Ohio. She is responsible for compliance, training, and management of parent

involvement and social service programs. Recently promoted

to this position, Kathleen was formerly a parent involvement

coordinator at WSEM-CDC and an AmeriCorp member. Her

voluntary activities include

service on the WSEM Youth

Services Advisory Board,

coordinator of an art show,

and member of the American

Bando Association in

Cleveland, Ohio. Kathleen

will work with the Program

Operations Division, Head

Start Bureau. She can

be reached at (202) 205-

8602, or by E=mail at: ksullivan@acf.dhhs.gov.

Wassy Tesfa is a Special Needs Specialist at Community

Housing Service/Head Start in Pasadena, California. Her

duties include the design, development, and implementation

of disability services for the program; collaboration; community outreach; and grant writing. Wassy has also held positions as a speech, language, and mental health consultant,

counselor for Ethiopian Community Center Outreach

Services, Inc., and as a freelance journalist for Radio

Voice of Germany in

Frankfurt, West Germany.

Her community service

includes the creation of

"Tesfa in Los Angeles," an initiative designed to rehabilitate homeless families in

Ethiopia, and serving as

founder of the Ethiopian

Human Rights Committee in

Los Angeles, California.

Wassy earned an MA degree

from Johannes Gutenberg University in Mainz, West

Germany, and a certificate from Studien Kolleg, Cologne,

West Germany. She will work with the Program Support

Division of the Head Start Bureau, and can be reached at

(202) 401-2962, or by E-mail at: wtesfa@acf.dhhs.gov.

The fax number for all Head Start Fellows is (202) 401-5916.

For more information on the National Head Start Fellows

Program, contact: JoAn Herren,Training and Technical Assistance

Branch Chief, Head Start Bureau T: 202-205-8566;

E: jherren@acf.dhhs.gov.
Oral Health

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Extra copies of the Forum Papers can be obtained by sending a fax request to the Head Start Information and

Publication Center at 202-737-1151.You can also download

them from the their Web site: http://www.headstartinfo.org.

A limited number of Healthy Smiles, Healthy Children buttons and posters will be available on a first come, first serve

basis through your regional QIC.Videotaped copies of the

Forum general sessions will also be available for purchase.

Information on how to order videos will be sent in the mail.

Extra copies of the Forum Papers!