1. Oral Health Program for Early Childhood Home Visiting Programs
Shellie Harden, DDS, MPH
Illinois Department of Human Services
Permission given to photocopy slides from Oral Health Training for Health Professionals. © 2004 by
National Maternal and Child Oral Health Resource Center, Georgetown University.

2. Training Objectives Enable Home Visitors to:
Understand & explain the importance of good oral health for mothers and babies.
Understand and address existing barriers to receiving oral health care.
Identify risks for Early Childhood Caries (ECC).
Discuss appropriate preventive practices for moms, infants, and young children and increase knowledge of caries prevention.
Identify ways to educate families on good oral health & resources for dental care.
Conduct an oral health risk assessment and document education and referrals to a dental home.
Disparities in Oral Health:
Children of Non-Hispanic African-American and Mexican-American heritage have a higher prevalence of untreated tooth decay than Non-Hispanic White children.
Interesting fact: 17 Healthy People 2020 objectives relate to oral health

3. The Importance of Good Oral Health in Moms
Good oral health in pregnancy and after:
can help prevent complications of dental diseases during pregnancy.
may reduce preterm and low birth weight deliveries (by preventing the progression of periodontal disease).
has the potential to decrease ECC in mom’s children.
Good periodontal health may reduce the development of pregnancy gingivitis and periodontitis (formally pyorrhea)…both forms of gum disease in which bacterial plaque plays a role.
Pregnant women with gum disease have ~ 4-7x greater risk of delivering pre-term and underweight babies.
The possible link between poor oral health and preterm and low-birth weight babies is related to the increase in prostaglandins which control inflammation and smooth muscle contraction. The increase in prostaglandins may trigger uterine contractions.
So what are the signs of periodontal disease that you can help your clients identify?
1. Gums are tender, red, and swollen.
2. Gums may bleed easily
3. Receding gums
4. Bad breath
You may want to ask clients if they have any of the above in addition to: toothache, known cavities, loose teeth, other problems in the mouth, and the time of the last dental visit

4. The Importance of Achieving and Maintaining Good Oral Health in Infants and Children
Caries is the most common chronic childhood disease.
More common than asthma and hay fever in children (Oral Health in America: Report of the US Surgeon General, 2000)
Expensive, painful, and disruptive to growth if left untreated
-Untreated decay is more prevalent among infants and children of low income families.
-In the most extreme cases of complications from dental caries, death can be the result.

5. The Importance of Good Oral Health in Infants and Children
Primary teeth are important to overall facial structure and physical development.
Healthy primary teeth ensure proper chewing and speech development.
Healthy teeth reduce or eliminate the pain associated with pain from tooth decay (decreases school absenteeism).
Health primary teeth maintain the space in the dental arch, until the permanent teeth erupt, and decrease the risk for tooth decay in the permanent teeth.
Proper chewing can facilitate proper intake of nutrients.

6. Addressing Barriers to Oral Care for Mom-to-Be
First, dispel the myths about oral health during pregnancy for expectant moms.
Identify individual barriers preventing mom-to-be from receiving dental care during pregnancy and take the time to educate her.
Myths:
1. You lose a tooth for every pregnancy.
2. Calcium is depleted during pregnancy.
You can’t get dental care while pregnant.
Potential Barriers:
Attitude: Do not perceive a need to go
No insurance, it costs too much, can’t find a dentist who accepts Medicaid
Didn’t want to go or too busy
No transportation
Believed dental care should not be done.
Obstetrician may have advised again getting dental care.
Lack of education on the importance of oral health
Geographic (i.e. low dentist to patient ratio)
The dentist won’t see pregnant women.
Education points:
Explain to mom and emphasize the connection between poor oral hygiene/health and pre-term low-birth weight babies.
Advise moms that dental care is safe and effective during pregnancy and can be done at any time with no additional risk compared to not receiving care.
Help her find a dental care provider where pregnant women are served in order to receive routine services such as exam, cleaning, and basic restorative treatment.

7. Preventive Practices for Mom (at Home)
Brush teeth at least twice a day (especially before bed) using a Fluoride toothpaste.
Try to floss daily… 
***Chew Xylitol gum daily and after meals.
Drink Fluoridated water and make healthy food choices.
If you smoke, stop!
Flossing…You may recall a recent media storm indicating that flossing is not important or necessary. Please do not listen to these reports and continue to try to floss your teeth and encourage your program clients to do the same.
Chewing Xylitol…chewing gum can lead to TMJ discomfort and also gastrointestinal upset. So I would advise to do so sparingly.
Smoking is a strong risk factor for periodontal disease, decreased salivary gland function, and immune dysfunction of mothers and children
Exposed to second-hand smoke.

8. Client side with visuals of a pregnant woman brushing – demo model at bottom assists client in viewing all surfaces to be brushed.

9. Client side explaining flossing and the importance of keeping a C shape around the tooth and gum. Again, demo model at bottom assists in viewing floss technique.

10. Preventive Practices and Professional Dental Care for Mom
General guidelines for dental care in pregnancy:
Same standard of care as general population after 1st trimester
Best time between 4th and 6th month
Dental emergencies creating severe pain can be treated during any trimester.
Lidocaine w/epinephrine can be used safely (w/proper aspiration) during pregnancy.
Avoid elective x-rays. If x-rays are needed for diagnostic purposes (dental emergency), then they can be done with protection.

11. Tooth Development and Identifying Risks for Early Childhood Caries (ECC)
20 Primary Teeth (generally by the age of 2-3 until 5-6 years old.
32 Permanent Teeth (including the four 3rd molars….or wisdom teeth)

12. This is a nice way to remember the decay process
This is a nice way to remember the decay process. Bacteria break down the food into acid which eventually eats away the tooth.

13. Client side emphasizing the need to look for initial white spots
Client side emphasizing the need to look for initial white spots. Often, these initial white spots can be haulted with correcting improper feeding practices and performing proper hygiene ie brushing and flossing and Fluoride treatment.
Early detection of dental caries in children is crucial because decay generally tends to progress rapidly in primary (or deciduous) teeth.

14. -Usually affects the upper incisors first, then the 1st and 2nd primary molars.
-Caries formation can also occur when the 1st teeth erupt.

15. Bacterial Transmission and ECC Risk
Bacterial transmission from adult to child via saliva
Other Modes of Transmission:
Child fingers in adult mouth
Adult tests bottle temperature with mouth
Adult shares utensils with child
Adult cleans pacifier with mouth
Poor oral hygiene in mothers and children
Active decay in mom or primary caregiver within 12 months
Bedtime bottles with juice, milk, or other sugary drinks
It’s important that parents and other primary caregivers practice good oral hygiene and avoid behaviors that transfer S. mutans to the child

17. ECC can also lead to poor self esteem, problems with speech development, poor chewing and poor nutrition, increased school absenteeism, increased visits to the emergency room
In adults, rampant decay can lead to hours lost at work and decreased work productivity.

18. Preventive Practices for Infants
Clean infant gums with a damp cloth, after feedings, even before tooth eruption.
Brush teeth 2-3 times a day (especially before bed), as soon as the first tooth erupts.
First dental exam by 12 months, but preferably as soon as first tooth erupts (American Association of Pediatrics and American Association of Pediatric Dentistry)
Tooth eruption: usually around 6 or 7 months old, but can occur as early as birth.
Toothbrushes for infants and children <2: use soft tooth brushes that are indicated for infant or child
Toothpaste amounts in infants: Use a “smear” for ages 2 and under and “pea size” for over 2
For brushing an infant or child’s teeth, lift the lips to brush the fronts and backs of teeth, all the way around the mouth, top and bottom. Focus on the gum line.
Some comments on teething: 1. Fever is not normal while teething Ease discomfort by rubbing the gums with a clean finger or wet gauze pad. 3. Do not rub alcohol in any form on the baby’s gums.

19. Preventive Practices for Infants and Dietary Practices
Breastfeeding decreases risk of developing tooth decay compared with bottle feeding.
Children who breastfeed for long periods throughout the day or night may develop tooth decay.
To reduce sugary fluids from pooling around the teeth, remove child from the breast when finished feeding.
Wean from bottle by months when more solid foods are consumed and baby is drinking from a cup.
Introduce small cup when child can sit up without support.
Water or milk between meals, with no more than 4-6 oz of 100% fruit juice per day (ages 1-5)
Breast milk does contain sugar.

20. Anticipatory Guidance for Infants and Other Prevention Practices
Water only in bottle at bedtime
Do not dip pacifiers in sweetened foods.
No prolonged bottle feedings
Other practices: clean pacifier, favorite blanket, reading baby to sleep
No saliva sharing habits (e.g., sharing utensils, cleaning pacifiers w/mouth)
No more than 4–6 ounces of 100 percent fruit juice per day
Foods w/sugar only at mealtimes and limit amount
No added cereal in the bottle
Anticipatory guidance can include oral development, tooth eruption, oral eruption, oral hygiene practices, Fluoride use, bottle use, dietary practices, and how to prevent S. mutans transmission.

21. Preventive/Hygiene Practices for Young Children (Age >2)
Similar tooth brushing tips as w/infants, except use pea-size amount of Fluoridated toothpaste
Young children do not have fine motor skills to brush adequately, so use hand-over-hand guidance or brush the child’s teeth again.
Make sure the child spits the toothpaste out. Some oral health professionals will say to then have the child rinse with water and some will say that it’s ok not to rinse after spitting out the toothpaste.

22. Toothpaste Amounts “Smear” “Pea Size” Ages 2 and Under Over Age 2
-The use of a smear of toothpaste when the teeth are first erupting is not an absolute and it is most important to introduce the mechanical motion of tooth brushing at the infancy stage more so than making sure to use toothpaste.
Fluoride and its role in Oral Health:
-natural mineral found in ground H2O, soil, and plants that enhances tooth and bone health
-doesn’t necessarily lower incidence of tooth decay but can help strengthen and re-mineralize weakened areas of enamel
-benefits are obtained either systemically, through drinking water and supplements, or topically via mouth rinses, gels, and varnishes
-Water fluoridation is one of the best examples of a Public Health preventive intervention at the community level.

23. Once the child has the ability to stand, the adult can sit in a chair with the child standing between the adult’s legs, facing away.  One hand is used to control head movement and keep the mouth open and the other to hold the toothbrush.
It’s important to brush all the surfaces on all the teeth, front and back.  An easy way to accomplish this is to start with the top back teeth on one side and progress to the front teeth and then the back teeth on the other side.  Drop down to the bottom teeth and repeat.  Brush the front surfaces of the teeth, the chewing surfaces and the back surfaces.  Brush each surface 10 times using gentle circular motions.  Singing to the child, while brushing, will make the experience more entertaining.

24. Preventive/Hygiene Practices for Children and Topical Fluoride
Topical Fluoride effective for children at high risk for decay if they live in area w/o fluoridated H2O or have history of tooth decay.
Use if the child frequently snacks on foods with high sugar content, or has a mechanical condition that makes them susceptible to decay.
Topical Fluoride is effective with minimal cost but should never be swallowed.
Almost all toothpaste sold in the US is fluoridated
Can also be applied as a varnish=a pale yellow topical Fluoride gel that’s “painted” on the teeth
Professionally applied varnish preferred for young children because it’s better tolerated and less likely to be swallowed.

25. Preventive/Hygiene Practices for Children and Dental Sealants
< 1/3 of children in the U.S. have sealants on their teeth.
Protect the chewing surfaces of the molar teeth
Placement is best soon after eruption (6 year and 12 year molars)

26. Sealant program offered through the IDPH:
-Targets high risk children
-Timing with 6 and 12 year molars

27. Discussion Questions:
A pregnant mother tells you that between taking care of her two children (ages 5, 2 years) and working full time, she doesn't have time to brush her teeth, let alone floss.
The dad of a 6 month old says that he wants to help take care of his son’s teeth but doesn’t know how or when to start.
A mom of a 22 month old says that she’s concerned because her son throws tantrums whenever she tries to brush his teeth.
What do you do?
You might want to re-emphasize to mom the importance of maintaining good oral hygiene practices, for herself, in order to set a good example for her children early. You might want to also let her know that if she develops caries and severe gum disease, as a result of poor oral hygiene, this could lead to missed days of work for her. One solution for her could be to at least brush and floss at night before she goes to bed.
For dad it could be as simple as having a brochure with illustrations on hand to help him get started. It could also be a matter of finding out when he has the time to help out and taking advantage of those moments.
For a child who throws tantrums to avoid tooth brushing, one strategy might be to turn it into a game. Another might be to engage him by allowing him to hold the toothbrush with you (hand-over-hand guidance).

28. Role of the Home Visitor in Assessing Oral Health
Oral Health Risk Assessment of mom and baby
Engage in Motivational Interviewing (from NC Headstart,
Provide education on oral hygiene, diet, dental care, and anticipatory guidance
Some questions that might be asked for oral health risk assessment:
What are the environmental risks (water source…ie is the water fluoridated)?
What are the family risks, parental beliefs, caregivers general health, oral hygiene or dietary practices?
What is the parent or caregiver’s ability to perform oral health screening of the infant/child? In other words, is the parent able to lift the lip and look for eruption of the teeth, plaque, white spots, or swellings in the gums?

29. American Academy of Pediatric Dentistry Risk Assessment Tool Questions
High Risk Factors
Moderate Risk Factors
Protective Factors
Biological Factors
Mother/primary caregiver has active cavities
Yes
Parent/caregiver has low socioeconomic status
Child has >3 between meal sugar-containing snacks or beverages per day
Child is put to bed with a bottle containing natural or added sugar
Child has special care needs
Child is a recent immigrant
Child receives optimally-fluoride drinking water or fluoride supplements
Child has teeth brushed daily with fluoridated toothpaste
Child receives topical fluoride from heath professional
Child has dental home/regular care
Clinical Findings
Child has white spot lesions or enamel defects
Child has visible cavities or fillings
Child has plaque on teeth

30. Parent Education and Resources for Home Visitors
Flip Chart
Posters
Video
Handouts and Fact Sheets
Office Newsletters
Community Activities
Repetition and reinforcement
mychildrensteeth.org

31. Dental Referrals and the Dental Home
Refer woman or child who has immediate oral health problems or is at high risk for tooth decay to a local dentist. Document your work!
For assistance in locating a dentist contact local or state dental societies: American Dental Association (ADA), Academy of General Dentistry (AGD), American Academy of Pediatric Dentistry (AAPD)
According to the AAPD, the Dental Home is defined as the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate.

32. References AAP.org aapd.org ada.org dentistryiq.com dph.illinois.gov
hdassoc.org
mychildrensteeth.org
NC Headstart,
oralhealthgroup.com
Oral Health in America: A Report of the Surgeon General, National Institute of Dental and Craniofacial Research, National Institutes of Health, U.S. Department of Health and Human Services (DHHS), 2000.