Head Start 2007 Program Instruction in Oral Health – Making It Happen & other Tips

1. Head Start 2007 Program Instruction in Oral Health – Making It Happen & other Tips Reg Louie, DDS, MPH California Head Start Association Summer Manager & Director Institute Sacramento, CA August 1, 2007

2. Link to Website for Program Instruction in Oral Health • http://www.mchoralhealth.org/HeadStart/index.html • Other helpful information will also be found at this site

3. Toothbrushing for children age two and over “Once daily, after a meal, Head Start staff (or volunteers, if available) should assist children in brushing their teeth using a small smear of toothpaste that contains fluoride”

4. Others rush through it carelessly? Toothbrushing.. Are some children reluctant?

5. Make it a group activity…for learning..and fun.. and better oral health

6. Advantages • A calm systematic way to teach oral hygiene and accomplish daily requirements • Children see their teacher brushing – role modeling • Able to monitor amount of time each child brushes • Ability to observe techniques sitting at children’s level, rather than standing by a sink

7. Using an egg timer allows children to learn how long they should be brushing and monitor their progress

8. In Head Start, when to brush? • Once daily • After the meal

9. 1 & 2 - paper towels (table cloth & napkin) 3 - Less than pea size toothpaste on cup rim 4 - Cup for spitting Note: no water in the cup 3 The equipment 4 2 1

10. 1. Toothpaste with fluoride 2. Less than pea size… 3. Put it on the rim….. The toothpaste tube does not touch any toothbrushes – no germs are shared

11. Toothbrushing is role modeled, monitored for cleaning all parts of the mouth and using adequate time

12. Brush, brush, brush Scrubbing is fine. Don’t expect circles at this age

13. Spitting (to avoid swallowing toothpaste) is role modeled and monitored No rinsing is needed

14. Use the napkin

15. Put the napkin in the cup to absorb liquid ..and dispose of the paper and cup

16. Rinse the brush

17. Stow the brush for drying

18. Many Methods of Toothbrush Storage: separation and drying are essential

19. No toothbrush covers needed Ventilation holes Spacious compartments for drying Wash drawers in a dishwasher prevdentsp@aol.com $24.99 A system to consider

20. Not role modeled Varied amounts of brushing time Technique may note be as closely monitored One child at a time is more time consuming Uses water; toothpaste more likely to be swallowed

21. For children between one and two years of age • Once daily, after a meal, Head Start staff (or volunteers, if available) must brush children’s teeth with a soft bristled toothbrush, using a small smear of toothpaste that contains fluoride

22. Enables the child to begin learning how to brush Toothbrush adaptations for 1-2 year old children

23. Dispensing toothpaste for 1-2 year old children • Avoid spreading germs • Dispense toothpaste onto a tongue blade, and wipe it onto the brush or • Use individual small tubes of toothpaste

24. For infants under the age of one “At least once during the program day, staff or volunteers must wash their hands and then cover a finger with a gauze pad or soft cloth and gently wipe infants’ gums”

25. Should gloves be worn while brushing 1-2 year old children’s teeth or wiping infant’s gums? • Gloves are not usually required, but wash hands before and after brushing each child’s teeth or wiping gums. • If glove are worn, be alert to possible latex allergies; wear latex free gloves

26. Other Tips for Oral Health and Partnerships in Head Start

27. Helping Parents Whose Children Are Not Up-To-Date Includes, but not limited to: • Education about importance of prevention and care • Identify dentists who accept Medi-Cal or Healthy Families or provide free/low-cost services • Arrange transportation to dental office • Provide transportation (with written consent) • Bring dentist or mobile clinic to Head Start

28. Who are appropriate dental professionals for examination and treatment ? • Most states, including CA, require that a dentist performs the examination, which results in a definitive diagnosis and treatment plan, and provides or supervises treatment • Some states allow dental hygienists to provide assessment, triage and referral • Dental screening by a non-dentist is not required and does not fulfill the examination requirement

29. Why is Providing Dental Services a Challenging Task • Many dentists • Don’t accept patients with Medi-Cal/Heathy Families (SCHIP) • Don’t accept very young children • Parents • Many parents don’t complete exams and treatment prior to enrollment (for many reasons) • Parents can’t be required to provide exams and treatment prior to enrollment • Parents may be unfamiliar with the dental care system

30. Dental Provider Shortages? A limited solution for providing dental examinations: • Local dentists may be willing to provide examination at the Head Start site • A mobile dental clinic may be engaged to provide examinations/ treatment on site

31. Benefits of Onsite Exams • Can avoid transporting children in small groups to dental office: inefficient use of personnel time • Identifies the ~ 25-35% of enrollees who will need follow-up care – only those who’ll need for follow-up care will need to be transported to a dental office • Can provide exams and fluoride varnish to fulfill two PIR reporting items (cleaning not required) • Dentist(s) will see extent of need and have a better understanding of Head Start’s role and accomplishments … BUT the goal is …

32. The Goal – A Dental Home A source of continuous, accessible comprehensive, family-centered, coordinated, compassionate, and culturally effective oral health care delivered or directed by a licensed professional dentist

33. Making the contact • Don’t assume a local dentist won’t help, based on previous refusals – try again with a different approach • Contact the president of the local dental society to inform of the intention of recruitment • Ask for recommendations of whom to contact first • Ask for a few minutes on a Board of Directors meeting agenda to describe Head Start and ask for dentists to participate • Use phone book for listing of all local dentists • Contact as many dentists as possible, but let all know who has already agreed to help. Foster collaboration among the dentists. • Recruit for exams and fluoride varnish, even if they won’t immediately agree to do follow-up • Seek the help of other health care providers as advocates, e.g., pediatricians, nurses

34. What to Discuss • Describe Head Start: • Stress that it is a comprehensive child development program and underscore the differences from other pre-school programs • Why Head Start is important in your community • How other agencies/individuals in your community help Head Start fulfill health related requirements • Outline Head Start requirements for dental services • Describe ways in which Head Start can and will help the dentist(s) provide services for the children

35. Understand Incentives for Dentists • Don’t expect or ask dentists to volunteer • Will not promote sustainability – likely to volunteer one year but perhaps not ongoing • If they are willing to volunteer they will offer • Promote accepting Medi-Cal fees • Do the math • # kids x exam fee + fluoride varnish fee • For example for 50 children • Examination = $25.00 • Fluoride = $5.00 • 50 children = $1,500.00 • 50-75 children can be examined in a day

36. Incentive for dentists (cont.) • Media coverage including a photo of the participating local dentist(s) • Especially important in smaller towns • Help the dentists understand their role in helping Head Start to survive/thrive in their community • Without dentists’ help Head Start cannot fulfill a required Performance Standard • Providing exams on site will eliminate one of the most frequently cited reasons for dentists not accepting Medi-Cal patients, i.e., failure to show up for appointments

37. Providing On-site Exams May Encourage Providing Follow-up Dental Services • Through providing examinations on-site at Head Start, local dentists will: • See the extent of dental need among the children • Have a greater understanding and value for Head Start through being on-site and observing the program • See that most of the children are very cooperative

38. Equipment & Supplies to Provide Onsite Exams • Equipment • Portable dental equipment • Cost: Approximately $2,000 • Durability: • Decades • Can share cost & use with other sites/ programs • Supplies • Gloves, masks, disposable paper clinic gowns, disposable mirrors & explorers, dose pack fluoride varnish • Cost: approximately $1.50 per child

39. Equipment to Provide • Portable equipment will make it possible to do a thorough examination • Adjustable Chair = good positioning • Operator’s stool = dentist’s comfort • Adjustable light = good visibility

40. Offer Help • Offer to: • Supply a person to record examination results • Supply a person to get the children from classrooms and return them • Put a name tag on each child to assure accurate records • Provide a translator if needed • Promise to make it well organized AND MAKE IT WELL ORGANIZED

41. Offer Help (continued) Offer to fill-out and submit Medicaid forms • Will eliminate one of most frequently cited reasons for not accepting Medi-Cal patients – Medi-Cal paperwork • Don’t expect to cover Head Start personnel costs for this effort – consider it an investment in obtaining services • Will be especially appealing to retired dentists who do not have an office staff

42. Invite parents to come to the Head Start site to be present during the examination • Allows the dentist to talk with parents about their child’s oral health • Educational for parents • Begins to establish parent/dentist rapport

43. Additional Strategies/Issues:Promoting Partnership with CA Children’s Dental Disease Prevention Program • Direct provision of preventive services to preschool/school kids • Contribute to achievement of HP2010 Oral Health Objectives • Development of community resources for preventive services and community participation in advocating for preventive oral health services for children • Provision of oral health education services

44. Additional Strategies/Issues:Promoting Partnership with CCDDPP (2) • CCD2P2 Brings to the Table • Classroom Experienced Staff • Client follow-up • Continuation of Education • Preventive Care for Clients • Access to Schools • Collaboration Outcome • Continuity of Education • Shared Resources • Parent Involvement • Stronger Advocates for Oral Health • United Front • Healthier Children – Healthier Families

45. Additional Strategies/Issues:Promoting Partnership with CCDDPP (3) • Respective Advisory Groups • HS Health Services Advisory Committee • Local DDPP Advisory Group • Program Planning • N/A’s and Plan Development • Health Education/Promotion Efforts • Target priority populations, e.g., EHS • Share curricula • Co-train • Provider Pools • Cultivate referral pools and share

46. Additional Strategies/Issues:Promoting understanding • Include a dentist and dental hygienist on the Health Services Advisory Committee • Mid-career dentists may be more willing to volunteer

47. Additional Strategies/Issues: Waivers - Parental refusal to consent to dental examinations & treatment • Assure translation of information into their first language • Examine reasons if more than a few parents refuse dental examinations and treatment

48. Additional Strategies/Issues: If you can’t find a local dentist…..Mobile programs – what to ask • What services does the mobile dental program provide? • Preventive only? • Can fulfill examination and preventive requirements • Requires cooperation with local dentists to provide follow-up care? Do the local dentists endorse the mobile program? • Restorative? • Can fulfill all dental requirements • What are the arrangements for follow-up care for emergency needs? • Do they have a local permanent site for follow-up care or emergencies? • Are x-rays readily available to be mailed to another dentist? • Are they endorsed by or have good communication with the local dentists?

49. Additional Strategies/Issues: Fluoride Varnish • Fluoride Varnish is a new method of providing topical fluoride – fluoride adheres to teeth longer to make treatment last longer • Children from low income families are at higher risk for dental decay and therefore are more likely to need fluoride treatment • Fluoride varnish is new (in US) and not yet used by many private dental offices: Head Start should offer to provide it • Optimal for Head Start programs because: • Low dose of fluoride for young children • Does not require prophylaxis (cleaning) • Can be done at the Head Start site together with examination • In many states can be done by a dental hygienist • Medi-Cal reimbursable

50. Additional Strategies/Issues: Approach dental and dental hygiene schools for help with examinations and follow-up care • Call the school - ask for the director of community-based programs • Dental hygiene schools have dentist faculty supervisors • May consider bringing dental hygiene students for community experience to: • Provide classroom education • screenings and fluoride varnish done by students followed by exam by faculty dentist (fulfill exam requirement) • Call the school – ask for the director of community-based programs or dental public health teacher