According to estimates, almost 40% of 2- to 8-year-olds experience tooth decay,¹ an oral disease that is five times more common than childhood asthma. Oral disease causes pain and problems with eating, speaking, learning, and sleeping. Children may suffer from inattention and distractibility, thus impacting readiness for school.² Additionally, young children who are still developing their language skills may be unable to express the pain they are experiencing.

Living with constant oral pain is far too heavy a burden to place on young children while they are rapidly growing and developing. This is unacceptable, given that dental decay is almost 100% preventable and oral disease prevention strategies are well understood.³

How does an early learning program use current knowledge about oral disease prevention to improve the oral health of young children? Program managers can develop and implement oral health and nutrition policies and practices to reduce oral disease within the classroom or family child care setting.⁴ During daily routines, teachers can integrate healthy eating and oral hygiene habits to show children how to prevent dental decay. Healthy self-care behaviors, such as supervised toothbrushing with fluoride toothpaste, introduce young children to healthy routines to prevent oral disease.⁵ Also, programs are poised to provide essential information to families about how to prevent dental decay and promote children’s oral health. Managers and staff can share current information with parents about the importance of oral health to overall health. Ongoing communication helps encourage families to incorporate healthy oral hygiene behaviors at home, too. Below are strategies you can use in your program.

Actively Promote Oral Health

Early learning programs can raise awareness to promote oral health by sharing several current recommendations from the American Dental Association (ADA):⁶

• For children younger than 3 years, brush children’s teeth as soon as they begin to come into the mouth by using fluoride toothpaste in an amount no more than a smear or the size of a grain of rice.
• For children 3 to 6 years of age, caregivers should dispense no more than a pea-sized amount of fluoride toothpaste.
• Brush teeth thoroughly twice per day (ideally, after breakfast and before bed).

Also important to remember:

• Children should be supervised and assisted with tooth brushing until age 7 or 8.
• Replace toothbrushes when bristles appear worn or frayed (usually after 3-6 months).
• Toothbrushes or other oral items (such as pacifiers or eating utensils) should not be shared.

Encourage Proper Toothbrushing Routines 

Parents, staff, and caregivers may need to see the difference between a ‘smear’ and a ‘pea-sized’ amount of toothpaste.  When looking at the photo below, the toothbrush on the top shows a ‘smear’ of toothpaste, recommended for ­children under 3, and the toothbrush on the bottom shows a ‘pea-sized’ amount, recommended for children 3 to 6 years.

Tooth decay comes from the combination of sugar found in food and beverages and bacteria that appear normally on teeth. The bacteria in your mouth turn sugar into an acid that can lead to tooth decay. Normal saliva production, fluoride, and healthy eating habits are things all people can do to prevent tooth decay. However, the key to preventing tooth decay is using basic oral health habits. These include brushing for 2 minutes with fluoride toothpaste 2 times per day, drinking fluoridated water, and eating regularly scheduled meals and snacks. It’s important to brush before bed because less saliva (a protective factor) is produced during sleep.

Teachers and parents should supervise toothbrushing because it is a fine motor skill that takes time to learn and improve with repeated practice. Direct hands-on supervision by adults is necessary until children are about 7 or 8 years old (or until they can write cursive). Parents need to be educated about these developmental considerations.

Incorporate a Group Toothbrushing Protocol in Your Program

Group toothbrushing policies and procedures help young children build oral hygiene skills. In this approach, all of the children and teachers brush their teeth together helping children learn through imitating models. Children enjoy brushing to music or when adults sing a favorite song for two minutes. Here are some suggestions for incorporating group toothbrushing in the classroom:

Brush teeth in a group after meals. Children sit down as a group at a table and brush their teeth for 2 minutes without rinsing, along with the teacher. This approach is easier than standing at a sink to brush, as it avoids a wet mess and sharing of germs.

Use fluoride toothpaste for all ­children. Use only a ‘smear’ for ­children less than 3, and a ‘pea-sized’ amount for children 3 to 6. With such a tiny amount of toothpaste, children do not need to rinse.

Review this step-by-step guide to “Classroom Circle Brushing” on the Indian Health Service Head Start program website: www.ihs.gov/headstart/documents/ClassroomCircleBrushingPoster.pdf

Carefully store toothbrushes in an upright position to air dry and if stored in the same holder, there is enough space between the toothbrushes that they do not touch to prevent cross-contamination of bacteria. Use CDC’s guidelines on the use and handling of toothbrushes to make sure toothbrushes are stored correctly (www.cdc.gov/oralhealth/infectioncontrol/factsheets/toothbrushes.htm).

Reach out to a local community service organization, such as the Rotary Club, to donate toothbrushes and toothpaste supplies. Local and state dental and dental hygiene societies may also be contacted for donations.

Be Aware of Sources for Fluoride 

There are many benefits to using fluoride as part of an oral care program:

1. It makes teeth stronger and more resistant to tooth decay.
2. It lowers bacteria’s ability to produce acid.
3. It repairs early stages of tooth decay.

The three most common sources of fluoride are fluoride in community water, fluoride toothpaste, and topical fluoride applications provided by oral health and health providers. Helping ensure families have access to these resources will improve children’s oral health.

Promote the Relationship between Nutrition and Oral Health

A healthy diet is important for overall health, but the frequency with which a child snacks has more of an impact on his or her risk of developing tooth decay. Program managers and staff can share information and model healthy nutrition habits during the program day to help improve the oral health of children.⁷ Some strategies to use in your program and share with parents include:

• Limit juice intake to 4-6 ounces daily; serve only 100% juice or don’t serve juice at all.
• Children under 6 months should not be served fruit juice.
• Juice should never be served in a sippy cup.
• A healthier alternative to serving juice is whole fruit cut into bite-size pieces appropriate for the child’s age.
• Encourage fruits and vegetables at snacks and meals. Avoid sticky foods such as candy, cookies, cake, or raisins and other dried fruit.
• Offer water or milk between meals. Make water freely available. Ideally, use safe and drinkable fluoridated tap water. Test tap water regularly for unsafe contaminants.
• While seated, offer a regular cup to drink from (not a sippy cup) with just a few ounces.
• Brush teeth after children take chewable or syrup-based medications since many medications contain sugar. If possible, give these medications to children at meal or snack times when the acid levels in their mouths will normally be higher.

Promote the First Dental Visit by the First Birthday

Encourage parents and expectant families to prevent dental disease by visiting the dentist within 6 months of the first tooth coming into the child’s mouth or by the child’s first birthday — whichever comes first. Families may need assistance to obtain insurance coverage and access to dental services through a ‘dental home’ — an ongoing relationship between the dentist and the patient. The dental home focuses on all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.⁸ Many community health centers now provide comprehensive pediatric dental services for routine preventive and follow-up care. You can promote oral health literacy for parents, staff, and caregivers by posting key messages on bulletin boards and in your newsletters.

Use Healthy Habits for Happy Smiles handouts: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/oral-health/education-activities/healthy-habits.html

Use the Healthy Mouth! Healthy Food! Healthy Children! poster: www.ecels-healthychildcarepa.org/tools/posters/item/431-oral-health-poster

Use Brush Up On Oral Health newsletters: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/oral-health/policies-procedures/buoh.html

Use Think Teeth resources at: www.insurekidsnow.gov/professionals/dental/index.html

Understand Oral Health Disparities and Connect Families to Services

Despite significant efforts to assist all families in accessing comprehensive oral health care services, low-income and other vulnerable populations continue to have high levels of dental disease.⁹ Understanding the barriers may help programs find solutions. These barriers may include:

• Shortage of dentists accepting Medical Assistance or Medicaid or the Children’s Health Insurance Program (CHIP).
• Lack of oral health educational resources for families, especially in different languages.
• Difficulties keeping appointments due to transportation barriers, such as no car or no access to public transportation, leading to ‘no-shows.’

Increasing a family’s oral health literacy addresses some of these barriers. Health literacy is a person’s ability to access, analyze, and use information to make decisions about his or her health. Fortunately, various oral health curricula are available to early learning programs in English and other languages. These curricula describe effective oral health practices for families, staff, and children through fun and engaging activities. Using an oral health curriculum to engage children and parents will build and reinforce the value of oral health care and a dental home.

Help prevent dental disease in children in your care by using these resources:

• Find oral health education curricula at the National Maternal and Child Oral Health Resource Center at Georgetown University:
  http://mchoralhealth.org/headstart/curricula/index.php
• Use Cavity Free Kids educational resources: www.cavityfreekids.org
• Use the 7 Ways You Can Share Oral Health Education Materials:
  https://www.insurekidsnow.gov/downloads/library/misc/ideas-7waystoshareoralhealth-english.pdf
• Use dental health campaign materials from the Ad Council:
  www.adcouncil.org/Our-Campaigns/Health/Children-s-Oral-Health
• Use the Brush My Smile video from the oral health component of I Am Moving, I Am Learning curriculum: www.youtube.com/watch?v=4rStiY7GDdY

Staff should remind parents of ­children enrolled in Medicaid or CHIP that they have coverage for dental services. These programs typically cover all dental exams, x-rays, fluoride treatments, dental sealants, and fillings. Be sure to check out your state’s complete list of benefits for children in Medicaid and CHIP and share this information with parents by accessing the national Insure Kids Now website: www.insurekidsnow.gov/initiatives/oral-health/index.html

As a trusted partner in the community, early learning programs offer unique support for children and families in building healthy habits to promote oral health. Creating program policies, planning oral health and nutrition activities, and promoting families’ oral health literacy can reduce the risk of dental disease for all children and improve their wellbeing.

End Notes

1 CDC/NCHS, National Health and Nutrition Examination Survey, Figure 1. Prevalence of dental caries in primary teeth, by age and race and Hispanic origin among children aged 2-8 years: United States, 2011-2012.

2 U.S. General Accounting Office. (2000). Oral health: Dental disease is a chronic problem among low-income populations. Washington, DC: U.S. General Accounting Office. www.gao.gov/
new.items/he00072.pdf

3 Institute of Medicine, Committee on an Oral Health Initiative. (2011). Advancing oral health in America. Washington, DC: National Academies Press.

4 Kim, J., Kaste, L. M., Fadavi, S., Benjamin Neelon, S. E. (2012). Are state child care regulations meeting national oral health and nutrition standards? Pediatric Dentistry, 34(4):317-324.

5 American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. (2013). Oral health in child care and early education. Applicable standards from: Caring for our children: National health and safety performance standards; Guidelines for early care and education programs (3rd edition). Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association; Aurora, CO: National Resource Center for Health and Safety in Child Care and Early Education. http://cfoc.nrckids.org/StandardView/SpcCol/Oral-Health

6 American Dental Association Council on Scientific Affairs. (2014). Fluoride toothpaste use for young children. JADA, 145(2):190-191.

7 Wright, J. T., Hanson, N., Ristic, H., Whall, C. W., Estrich, C. G., Zentz, R. R. (2014). Fluoride toothpaste efficacy and safety in children younger than 6 years: A systematic review. JADA, 145(2):182-189.

8 American Academy of Pediatric Dentistry, Council on Clinical Affairs. (2015). Definition of dental home. www.aapd.org/media/policies_guidelines/d_dentalhome.pdf

9 U.S. General Accounting Office. (2000). Oral health: Dental disease is a chronic problem among low-income populations. Washington, DC: U. S. General Accounting Office.  www.gao.gov/new.items/he00072.pdf

View or download full article at: https://www.childcareexchange.com/article/beyond-the-tooth-fairy/5023116/

ABOUT THE AUTHOR:

Amy Requa, MSN, CRNP, CPNP-PC, is a board certified Pediatric Nurse Practitioner in Primary Care and the State Oral Health Coordinator for the Pennsylvania Head Start Association. She received her Master’s Degree in Nursing from The University of Iowa in 1997. Ms. Requa has over 20 years of experience in public health nursing, maternal and child health, family and community health promotion, in-program director, project management, clinical, and training and technical assistance roles. Ms. Requa was mentored by Dr. Susan S. Aronson, MD, FAAP, as a Training and Technical Assistance Coordinator and Program Director for the Early Childhood Education Linkage System (ECELS) at the Pennsylvania Chapter of the American Academy of Pediatrics. Ms. Requa has co-authored award-winning childhood obesity prevention programs and multidisciplinary oral health literacy programs for human services professionals, medical and dental professionals, early learning practitioners, home visitors, parents, and children. Ms. Requa was the Health Content Specialist for the Office of Head Start in federal Region III from 2003-2010. She received the Administration for Children and Families’ Partnering for HHS Excellence Award from the US Department of Health and Human Services for her instrumental teamwork and leadership for the Office of Head Start on the early childhood obesity prevention initiative “I Am Moving, I Am Learning.”