1. “First Tooth” is an evidence-based program designed to decrease tooth decay in young children through education, preventative services and referrals.
I’d like to go over with you the training materials. This is a 4 module training, modified for the Head Start audience.
To begin with….many names have been used for tooth decay in young children such as baby bottle mouth, baby bottle caries, and nursing bottle syndrome. The term “early childhood caries” was adopted as the standard name for “the presence of one or more decayed primary teeth of a child 6 years of age or younger”. So early childhood caries is the process of cavity formation in young children.
Preventing early childhood caries through medical and dental provider education and collaboration

2. “First Tooth” for Head Start/Child care providers
Project goals:
Educate Head Start staff and child care providers on prevention of early childhood caries.
Train local oral health educators to provide education for non-dental/non-medical child care providers.
Facilitate collaborative referral relationships between WIC/HS staff /child care providers, dental providers and primary medical care providers so that all Oregon children have a dental home.
The main goal of this project is to educate child care providers and staff of HS, so that they can provide education for the prevention of early childhood caries to their families. These non-dental health professionals can be engaged as partners to advocate and support early childhood oral health.
Another goal is to be able to have local oral health champions, like myself, provide this education and help you build collaborative relationships with dental providers to improve access for your children.
First Tooth works diligently to facilitate collaborative referral relationships between WIC, Head Start schools, medical and dental providers, as well as any entity who sees children in the 0-3 year old population, so that there is consistent oral health messaging and that all children have access to a dental home.

3. Early Childhood Caries
The prevalence and
impact of
Early Childhood Caries
Let’s get started with discussing the prevalence and impact of early childhood caries.

4. Defining early childhood caries
Process of demineralization to cavities in primary dentition
Lesions can progress rapidly
Affects teeth least protected by saliva
Often associated with bottle or sippy cup use throughout the day or at night
Caries is a process of decay from early demineralization of the tooth structure to actual cavities, or holes, in the tooth. Early childhood caries occurs in the primary teeth of infants and young children. This condition can progress very rapidly due to the enamel of primary teeth being thinner than that of permanent teeth. ECC affects the teeth that are least protected by saliva, such as the upper front teeth. While ECC is often associated with the use of frequent bottle feeding at naptime and bedtime, this is not the exclusive cause.
How many of you have seen children with ECC?

5. Early childhood caries can lead to…
Extreme pain/no pain
Spread of infection and cellulitis
Psychological/Developmental Impairment:
Inability to concentrate
Malaise, low grade fever
Impaired language development
Low self-esteem
Long term affects:
Malocclusion
Extensive dental treatment
High risk of developing tooth decay in permanent teeth
One of the most distinguishing characteristics of ECC, as apposed to adult caries, is that altho a child might have pain with severely decayed teeth, most often they do not have any pain, or they do not register it as pain. Some children may be picky about the foods they eat because they don’t like the way food feels in their mouth (crunchy carrots, for instance.) They may also not mention if something hurts in their mouth because of fear of getting treatment (they may have older siblings or parents who have expressed fears or anxiety.)
There are many short-term and long-term affects early childhood caries can have on children. The child may experience acute pain, with infection and risk of cellulitis, but chronic pain can manifest itself in the inability to concentrate, malaise, low grade fever, impaired language development, and low self-esteem.
Long-term affects of early childhood caries include malocclusion or misalignment of the teeth, extensive and costly dental treatment initially and over the lifetime of the child, and increased likelihood of chronic tooth decay even in permanent teeth. 5 5 5

6. Current status of children’s oral health
Every 5 years the State oral health unit does a Smile survey which helps determine the extent of caries in Oregon's children.
As you can see, between 2002 and 2007 we saw an increase in decay and severity of decay. In there was increased activity in preventing decay throughout the state through First Tooth, increased access in Head Start, and sealant programs, to list a few. Fortunately, in 2012, we have seen improvement in these numbers. We need to continue to increase those preventative efforts to have even better success.

7. Disparities in Oregon children’s oral health
Hispanic/Latino children have higher
Rates of decay, untreated decay and
Rampant decay.
Black/African American children have
Higher rates of untreated decay.
Not surprisingly, the Smile survey also showed the disparities in oral health between Ethnic diverse children, and socioeconomically disadvantaged children.
Why might children from ethnically diverse backgrounds, primarily Hispanic and African American, have higher rates of decay?
What puts children from lower socioeconomic homes at higher risk of decay?
Children from lower income homes
have nearly twice the decay rates,
untreated decay and rampant decay
than children from higher income homes.

8. Why Head Start staff/child care providers?
They have frequent contact with pregnant moms, infants and children.
They teach children how to brush to prevent or reduce the risk of tooth decay.
They provide nutritional information that can reduce tooth decay.
Children in low socio-economic homes have higher rates of decay.
So why are we training child care providers? You have much more contact with families at risk of decay, from pregnancy through children.
Providing consistent oral health messages can prevent and reduce decay. In addition to providing quality educational materials to the families, you are in a position to show children and families how to care for teeth. Caregivers of young children tend to underestimate oral disease in their children, so when you have a basic knowledge of early childhood caries, you can educate your families on the importance of early access to a dental home and disease prevention.
Head Start provides nutrition education and healthcare referrals to low-income pregnant, breastfeeding, and postpartum women, and to infants and children up to age five who are found to be at nutritional risk. Oral health education messages can be easily integrated into the nutrition messages you are already providing.
Since families enrolled in HS serve families of low income, educating on disease prevention and early access to a dental home is very important. 8

9. Early childhood caries
and risk assessment
Lets look closely at the disease of early childhood caries and it’s risk factors.

10. First clinical signs of caries
White spots
Acids have demineralized enamel
First appear at gumline of upper front teeth
High risk for developing cavities
White spots can be remineralized with early intervention
Fluoride
Behavior modification: improved brushing & dietary habits
Indication for dental referral
Photo: Crest Slide Set and ICOHP
The first sign of caries is demineralization producing a “white spot”. White spots place the child at high risk for developing cavities and require immediate intervention because white spot lesions can be remineralized. White spot lesions first appear at the gum line of the upper front teeth, areas often missed while brushing and where there is limited saliva contact. As the child erupts more teeth, the gum line area is the first area to show signs of white spot lesions.
Immediate interventions include fluoride varnish, the use of fluoridated toothpaste, and behavioral modification for improved brushing and dietary habits. These early lesions CAN BE REVERSED with good oral hygiene, improved diet, and fluoride varnish applications.
Where dental care is available, make a timely referral to a dentist. Dental providers will apply extra topical fluoride and provide comprehensive treatment. Where dental care is delayed or unavailable, good oral hygiene and monthly applications of varnish for 3-6 months may reverse this early decay. Many WIC offices are providing fluoride varnish and education sessions for their clients through partnerships with local dental care organizations. (Example)
Used with permission by the Washington Dental Service Foundation 10

11. Example of fluorosis 2 Mild Fluorosis Severe Fluorosis
Fluorosis, a complication of ingesting excessive levels of fluoride while the teeth are forming, can also leave white spots. However, fluorosis affects the permanent teeth, giving them an overall lacy look, whereas demineralization white spots occur mainly at the base of the tooth along the gumline.
Mild Fluorosis
Severe Fluorosis

12. ECC disease progression
Photo: Crest Slide Set and ICOHP
These pictures show the progression of early childhood caries.
See pocket guide for progression of early childhood caries
See Head Start pocket guide 12

13. Severe caries Abscess See Head Start Pocket Guide
These pictures show the pattern of severe early childhood caries. Notice how cavity free the lower front teeth are, those teeth that are bathed in saliva the most. Also note the abscess in the lower left picture. It is important to lift the lip to assess the tissue at the area where the end of the tooth’s root is to determine if the tooth has abscessed.
See pocket guide flipchart - simplifies what to do when you see the stages.
See Head Start Pocket Guide 13

14. Caries process Requires 4 factors Tooth Bacteria Food source Time
There are four factors responsible for dental caries. Bacteria in dental plaque adheres to the tooth surface. There are many types of bacteria in the mouth and not all bacteria cause caries. Dental caries occurs when the oral bacteria Streptococci Mutans interacts with dietary carbohydrates, sucrose, fructose and lactose. The end product is acid, which over time, demineralizes or breaks down the tooth structure.
Used with permission by the Washington Dental Service Foundation 14

15. Caries process: ongoing balance
Protective Factors
Strength of the enamel
Fluoride
Adequate salivary flow
Pathologic Factors
Strep mutans
Carbohydrates
Reduced salivary flow
Caries, like other diseases our bodies are fighting, is a constant battle between protective factors and pathologic factors.
Protective factors include the strength of the enamel and the amount of salivary flow. Has there been adequate fluoride available to build and maintain hard tooth structure? Fluoride strengthens the structure of the teeth as they are forming when ingested systemically and makes the outer layer of enamel stronger when given topically. We also consider the amount of salivary flow. There should be adequate amounts of saliva present to buffer the acids and bring the mouth back to healthy pH levels, as well as rinse away food particles.
Pathologic factors include caries-causing bacteria, amount and frequency of fuel source for those bacteria, and reduced salivary flow. When there are too many pathological factors present, the teeth are at higher risk for caries. These must be counteracted by decreasing the pathological factors and increasing the protective factors.
No caries
Caries
Used with permission by the Washington Dental Service Foundation
Note: A printable version of the CAT is located in Section 3 of the speaker’s kit. Instructions for using the CAT can be obtained from the AAPD Web site at
Note: A printable version of the CAT is located in Section 3 of the speaker’s kit. Instructions for using the CAT can be obtained from the AAPD Web site at 15

16. Used with permission by the Washington Dental Service Foundation
Caries process and diet
← Plaque level acids →
Regular meals
Regular meals plus frequent snacks
This graph shows the difference between eating carbohydrates at mealtimes versus mealtimes and frequent snacking. Bacteria produce acids in the mouth for minutes after the ingestion of carbohydrates. The steady source of sugar/carbs results in almost continual exposure of the teeth to acid.
Remineralization occurs when acid is buffered, primarily by saliva. Frequent ingestion of carbohydrates, or the fuel source for the bacteria, then results in virtually no rest period for the enamel to remineralize. Is the mouth able to recover from the increase in acid production, or is it in a steady state of demineralization?
Practically speaking, the child will at least occasionally eat snacks or drink beverages with carbohydrates between meals. Encouraging carbohydrate rich foods to be limited to mealtimes and drinking water after snacks will help return the mouth to a healthy pH level.
Used with permission by the Washington Dental Service Foundation 16

17. There are certain foods that are more “tooth friendly” than others
There are certain foods that are more “tooth friendly” than others. This take home sheet for parents is a basic guide to choosing healthy snacks for oral health. It is available in English and Spanish. Notice that the healthy snack choices are those you are already likely to recommend. A way to integrate an oral health message might be when sharing recommended foods with your families to include that these foods can also help prevent cavities. It can be that simple.
Or you can use this as a handout for the family to paste on their refrigerator.

18. Caries process and transmission2
Caries process and transmission
Bacteria established by age 2
Natural process occurs through normal activities
Encourage regular dental care for pregnant women and mothers of infants
Xylitol can decrease caries risk
How do children get these cavity-causing bacteria? Transmission of oral bacteria is through saliva, in normal day-to-day activities. The transmission of oral bacteria appears to be primarily from mother to child, or from the person who spends the most waking hours with the child. Surprisingly, the child’s oral bacteria is determined by the time he is 2 years old! What kind of activities could increase this transmission of bacteria through saliva?
(Babies put their hands in the mouths of their mothers and into their own mouths, mothers clean pacifiers with their own mouths, saliva is shared by sharing utensils and toothbrushes.)
Recognizing that these bacteria are passed from mother to child makes it important to instill the message to the mother that her own oral health is important. If she can minimize the bacteria load in her mouth by improved oral health, she is less likely to pass pathologic bacteria to her child.
In addition to recommending regular dental care to pregnant women and mothers of young children, good oral hygiene and the use of xylitol gum can decrease the mother’s risk for caries, and decrease the number of bacteria she passes down to her child.
Key Messages then, are:
Don’t decrease loving contact with infants, but
Do decrease maternal oral bacteria
Consider Dental Referral of expectant mothers and those with infants and toddlers
See Handout and : Guidelines for Oral Health In Pregnancy 18

19. Why do pregnant women need a healthy mouth?2
Why do pregnant women need a healthy mouth?
Reduces bacteria in mouth that can cause caries and gingivitis
Less bacteria passed to baby in the first two years of baby’s life
Research has shown that having gum disease while pregnant may cause pre-term births or low birth weight
Mother learns importance of early dental intervention for her baby
Recognizing that these bacteria are passed from mother to child makes it important to instill the message to the mother that her own oral health is important. If she can minimize the bacteria load in her mouth by improved oral health, she is less likely to pass pathologic bacteria to her child. (don’t repeat this if you said it in the previous slide, if you already said it, you can say, “In addition to improving caries risk for the mother and the baby, a healthy mouth also decreases the severity of gum disease.” then continue)
There is research that supports the link between gum disease in the pregnant woman and unfavorable birth outcomes, low-birth weight or preterm deliveries.
Lastly, when the mother accesses dental care during pregnancy, she is usually given great information on the importance of early oral health care for her baby to prevent disease.
Research has shown that whether or not a pregnant pt had dental insurance benefits did not increase utilization of dental services, so it is important to educate pregnant women on the importance of getting proper dental care during pregnancy. (JADA 2009;140; )
What are some reasons pregnant women avoid going to the dentist? (access, dentists don’t want to treat preg women, fears for safety of dental tx, too much on their plate, etc) 19

20. Is dental treatment safe during pregnancy?2
Is dental treatment safe during pregnancy?
All dental treatment safe during pregnancy, including xrays, cleanings, fillings and extractions
Getting regular dental care during pregnancy can prevent gingivitis and improve the health of the gums, which often get red and puffy during pregnancy
Getting a dental infection during pregnancy can be dangerous to the mother and baby
There are many conflicting messages regarding safety of dental care during pregnancy. The National Consensus Statement on oral health care during pregnancy is an excellent resource for medical and dental providers. It outlines the importance of good oral health as well as early referral to a dental home for the pregnant woman. You can access this document at the website listed here.
Many people don’t know that good oral hygiene and regular dental care is important for the pregnant woman.
Pregnant women who have a dentist should continue their regular schedule of routine care. All pregnant women should see a dentist no later than the second trimester to make sure that they don’t have cavities that could lead to infection. Additionally, the dental provider may recommend xylitol gum or chlorohexidine rinses to reduce harmful bacteria. Pregnant women often have gingivitis and/or periodontitis while pregnant. By seeing the dental provider early in pregnancy, the pregnant woman will get valuable education on care of her mouth.
Neglecting dental care during pregnancy can lead to a more severe dental infection, which can put the mother and unborn child at risk, particularly if the treatment involves more aggressive medications and treatment options.
There is no evidence that shows having dental procedures completed during pregnancy is harmful. In fact, it is more harmful to the mother and the baby to put off dental treatment. The dental provider will time treatments to make the patient most comfortable and be able to complete treatment, particular urgent needs.
Many women who are pregnant do not know that it is safe to get dental treatment during pregnancy, so advocating for them to access their benefits is very important.
Please note, we cannot get more copies of this document any more. You can show YOUR copy of this consensus statement, but they will have to download it for themselves on this website address.
See : Oral Health During Pregnancy Consensus Statement 20

21. Giving your baby a head start on a healthy mouth2
Giving your baby a head start on a healthy mouth
Mother is often the family member who establishes good eating and brushing habits for entire family
Mothers should model good brushing and eating habits
Start brushing baby’s teeth as soon as the first tooth erupts
Only put breast milk, formula or plain water in bottles and sippy cups
Educating the pregnant mother on oral health for her and for her young child is a great way to encourage healthy oral health habits that can last a lifetime. The mother is often the person in the family who establishes eating patterns and hygiene patterns, so when she understands the importance of a healthy mouth and good nutrition, these habits can be instilled in the family early.
Here are some specific tips for pregnant women and mothers of babies.
Changes to your body when you are pregnant may make your gums sore, puffy, and red if you do not brush and floss every day.
- If you can’t brush your teeth because you feel sick, rinse your
mouth with water or a mouth rinse that has fluoride.
If you vomit, rinse your mouth with water. It is best to add a teaspoon of baking soda to the water to neutralize the acid in the mouth.
Brushing twice a day with fluoridated toothpaste will help keep the enamel of the teeth strong. Use just a small smear of toothpaste to reduce the likelihood of toothpaste causing nausea.
Minimize eating high carbohydrate snacks throughout the day, but choose tooth healthy snacks.
Start brushing babies teeth as soon as they erupt with a small smear of fluoridated toothpaste.
Avoid the temptation to put juice or sweet beverages in bottles or sippy cups. Establish the habit early of putting just plain water, or milk/formula in bottles and sippy cups. 21

22. Be conscientious of cultural diversity
Increased rate of dental caries in certain ethnic groups.
Beliefs about health, disease, diet and hygiene in different cultures may impact practices and child- rearing habits.
While ethnicity alone is not a risk factor for dental caries, there are certain populations that are at higher risk for dental caries than others. For example, the 2000 Surgeon General’s report stated that American Indian, African American and Hispanic children are disproportionately affected by caries, even controlling for socioeconomic factors. Among these populations there is an increased rate of dental caries and a decrease in dental visits.
Beliefs about health, disease, diet, and hygiene in different cultures may create additional oral health risk factors through dietary/feeding practices and child-rearing habits. 22

23. 2
Who is most at risk?
Fortunately, the medical provider has already gathered much of the information needed to assess caries risk. Medical histories and intake forms often have built in triggers to help gathering information. This is the OrOHC Caries Risk assessment for children 0-5. The AAP, AAPD and ADA all have caries risk assessments that can be used to determine the child’s risk for caries.
As you can see, many of these are things you are already determining when asking about dietary habits and contemplating medical issues.
We already discussed the transmissible nature of the disease, as well as food choices which can contribute to caries. We also discussed how fluoride strengthens the enamel and makes it less prone to acid attack. If a child has no access to a dental home or fluoride varnish through other sources, they are at higher risk.
Children from a low socioeconomic group have a higher risk of early childhood caries for many reasons. (If they didn’t already do this in module 1, have the attendees list these reasons, or at least some of them…A high risk factor for unmet dental needs is lack of dental insurance. OR has a complex Medicaid system that is often daunting and difficult to navigate, so sometimes even when children have insurance, they have unmet medical and dental needs. Parents without a regular source of dental care for themselves may not have a regular dentist or may not have resources to pay for dental care. In addition, they may have significant dental fears or they may not understand the importance of oral health for themselves or their children.
Children in rural areas suffer more untreated decay than children living in cities. There are fewer options for low income dental care in rural sites, and minimal transportation options to dental providers make accessing the care challenging.
Parents with less education are less likely to seek preventative dental services for themselves and their children.
Persons of low socioeconomic status may have a lower oral health literacy level, or the ability to understand and apply oral health messages.
The cost of fresh foods and healthy snack options is higher than for unhealthy snacks.)
Children with special health care needs are at particularly high risk for caries and other serious health problems. Even brushing the teeth on some children with special needs can be more challenging than for healthy children. ( I let the participants list how these children might be at higher risk than other children)
Additionally, many medications can put the teeth at risk for caries. Many medications reduce saliva flow. Oral suspensions for chronic diseases are usually high in sugar and have a thick, sticky texture. (I let the participants come up with this on their own by guiding them with questions)
It is important to educate parents on ways to minimize the destructive nature of these medications on the teeth. Brushing the teeth, or at least having the child rinse the mouth with water after taking the medications are two educational tips for parents. Tooth brushing techniques may need to be modified depending on the child’s health care needs. Sometimes powered toothbrushes or toothbrushes with larger handles are easier for parents and children to use.
It was mentioned that bacteria harbored in plaque puts a child at risk for caries, as does any white spot lesions.
If a child has two or more of these risk factors, they are at high risk of decay.
See handout and : OrOHC Caries Risk Assessment <6
Ref –Featherstone,JDB. The continuum of dental caries--evidence for a dynamic disease process. J Dent Res 2004, 83 Spec No C:39-C42,
Note: A printable version of the CAT is located in Section 3 of the speaker’s kit. Instructions for using the CAT can be obtained from the AAPD Web site at

24. Oral health education and anticipatory guidance for parents/caregivers
Are there any questions before we move on to the next module?
Our next module takes us through the education and anticipatory guidance to give the parents. It is one thing for us to understand the concepts, but it is sometimes difficult to teach using words or concepts that parents understand or are motivated towards change. Providing anticipatory guidance that is consistent with the messages the parent hears from the WIC or Head Start Program in a way that they can put it into practice is the key to behavior change.

25. Healthy primary teeth are important!3
Healthy primary teeth are important!
For normal development
For space maintainers
For cavity-free permanent teeth
For keeping treatment costs low
First Dental Visit
Ave. 5 Year Cost
Before age 1
$263
After age 1
$447
Misconceptions about the importance of baby teeth contribute to the reason children are not accessing dental care. It is new information for some people that primary teeth are important for normal development of their child. We have already discussed how baby teeth are important for normal development and overall health of the child.
Costs of treating severe Early childhood caries in the hospital can cost up to $10, According to CareOregon statistics, CareOregon hospital dentistry costs paid per member doubled between 2003 and Low-income children who have their first preventive dental visit by age one are not only less likely to have subsequent restorative or emergency room visits, but their average dentally related costs are almost 40% lower ($263 compared to $447) over a five year period than children who receive their first preventive visit after age one.

26. Motivational interviewing (MI)
MI techniques can help teach good oral health habits- for the child and for the parent
Since a child does not have the dexterity to do adequate brushing without assistance, MI techniques such as modeling techniques can help teach parents how to brush their child’s teeth at home.
Many parents have fears about getting dental treatment for their children, so using MI techniques such as summarization can help understand these fears so they can be addressed directly
MI techniques, such as encouraging incremental changes in behavior, are helpful when improving oral health habits at home.
Head Start educators have had lots of training in Motivational Interviewing. The techniques you already utilize with your families apply to oral health messaging also. If the parent is not engaged and interested in behavioral change, the child’s oral health will not improve. We cannot expect a two or three year old to make good choices and brush their teeth on their own.
Go thru each of these.

27. Anticipatory guidance3
Anticipatory guidance
Early childhood caries is:
TRANSMISSIBLE
PREVENTABLE
TREATABLE
When providing specific anticipatory guidance for parents, keep the message simple! Caries are transmissible, preventable and treatable! Our educational tools can aid you in providing timely information for parents. 27

28. MI menu of options See Motivational Interviewing Tool
This tool was adapted from the Indian Health service to help with motivational interviewing and can be used chair-side to give the parent a visual of changes they could choose to make in regards to the health of their child.
For example, you could say, “Here is a list of topics that came up so far during our conversation. Which of these would you like to focus on during our last few minutes together?” And then have the parent circle the one or two changes they would like to make by the next appointment.
As nutrition consultants, you are used to keeping messages simple. Use quick phrases such as, “choose fruits and vegetables for snacks” or “drink plain water between meals”. If the parent wants more details about the reasoning behind the suggestion, you can provide it.
See Motivational Interviewing Tool

29. Anticipatory guidance/education3
Anticipatory guidance/education
We designed our educational posters with the clinical office in mind with regards to size and content. There are posters which address pregnancy, babies and toddlers, as well as toothbrush and toothpaste tips. The posters are available in English and Spanish.
Our educational materials are designed to provide anticipatory guidance from pregnancy through toddlers. Anticipatory guidance is a teaching technique that focuses on the needs of a child at each stage of life. Practical, timely information for parents and other caregivers allows them to anticipate impending changes and maximize their child's oral and general health potential. We have created posters to help emphasize key messages to give the parents.
The pregnancy poster gives parents information about the importance of minimizing the transmission of disease to their child. The babies and preschooler posters summarize preventing caries through behavior modification.
We share our posters with WIC , Head Start and Early Head Start to improve the consistent messaging for the parents. Our goal is to encourage medical providers, dental providers, WIC counselors and Head Start counselors to teach consistent messages so that the parents can understand that they can prevent dental disease in their children. Consistent messages decreases confusion and reinforces oral health messages in the various places that patients and parents are receiving oral health messages.
The posters are also on the flash drive if you want to reprint more, or if you want to print in a smaller, hand out form to send home with families.
See : Posters 29

30. Use diverse formats for delivering oral health education
DVDs
AAP flip chart
Pocket guide
Posters
Handouts
Puppets or plastic models
Using different modes of education can reinforce key messages. There are many different ways to teach oral health to your patients. The DVD Early Childhood Caries, Healthy teeth Healthy Me or Get Healthy Now Sesame Street DVD can be played in a waiting room or during a nutrition class. The AAP flip chart and office pocket guide can also be used when working with parents. We have added several handouts on oral health and healthy eating tips in your folders and the resource binder. All of the materials can be found electronically on the First Tooth website.
As family advocates, you are very much aware of language barriers and health literacy that can make education a challenge. We advise educators to use an appropriate literacy level of medical terms, limiting unnecessary statistics or difficult concepts. We want them to strive to keep the information accurate while simplifying the message. Using handouts that include more pictures than words can help bridge these gaps in health literacy, as well as using more common words interchangeably with medical terms.
Head Start already has materials printed in the patient’s primary language, but you may want to have some of the First Tooth materials translated into other languages. When possible, English and Spanish versions have been posted to our website.

31. Diet and feeding: 0-12 months
Breastfeeding does not increase the risk for caries, but limit to meals
Hold infant for bottle and breastfeeding, minimizing pooling of milk on teeth
No bottles at bedtime/naptime (or use plain water only)
Introduce cup at 6 months, wean bottle at months
Avoid constant use of sippy cup, pacifier
Introduce appropriate snacks
Encourage rinsing the mouth out with water
Specific information for prevention of ECC through diet and feeding are similar to the information you are already advocating for as HS educators.
Breastfeeding does not increase the risk of ECC, unless the child feeds for long periods without cleaning the mouth (for instance, if a baby with teeth sleeps with Mom and breastfeeds all night.)
Encourage to hold the baby during feedings and not prop the baby against a bottle or the breast. Use water at night time to prevent pooling of milk in the mouth if the infant falls asleep with a bottle. We suggest weaning the infant from the bottle between months. The constant use of a sippy cup with anything but plain water in it can increase the amount of time there is acid-producing fluids in the mouth.
We discussed how snacking on carbohydrate rich foods, or “grazing,” doesn’t allow for saliva to buffer the acids in the mouth and return it to a healthy pH level. Some parents will continue to give several snacks throughout the day regardless of our suggestions. We encourage rinsing the mouth out with water after snacks or juice in order to return the mouth to a healthy balance. 31

32. Diet and feeding: toddlers
1 – 2 years
Discontinue bottle feeding at months
Limit juice to 6 oz once daily at mealtimes, or eliminate altogether
Avoid sweet, sticky snacks – dried fruit, crackers, candy
Reserve soda, candy and sweets for “special occasion” treats
2 and older
Choose fresh fruits, vegetables, or whole grain snacks
Wean from pacifier and thumb-sucking
As educators you are already encouraging parents to make healthy choices when preparing meals and snacks for their children. As the child gets older it is even more important to watch the carbohydrate rich snacks and juices, and encourage eating fresh fruits and vegetables for in-between meal snacks. Dried fruit and fruit leather act as concentrated sugar and can cause caries.
It is also good to remind parents that using a pacifier or thumb sucking can affect the shape of the mouth and how the top and bottom teeth line up, so wean from the pacifier and thumb by age 2 or 3 years old.
Since so much of this information you already give to your children and parents, adding a tag-line such as, “keep in mind that these healthy snack choices also can prevent your child from getting cavities” is a way to integrate anticipatory guidance.
Good preventive medicine for obesity too!
Used with permission by the Washington Dental Service Foundation 32

33. Oral hygiene < 1 year Clean gums with cloth or soft toothbrush
As teeth erupt, use smear of toothpaste 2x/day*
1-6 years
Brush 2X/day using half-pea-sized amount of fluoridated toothpaste
Parent/caregiver performs and supervises
Spit and don’t rinse
Practicing good oral hygiene is another way to prevent caries, and giving tips for improving daily oral hygiene can improve risk for caries and outcomes.
It is important for the parent to know how to view their child’s teeth. You can show the parent the lap method, which is similar to the knee-to-knee screening that a provider may do. Another way is to have the child sit in the parents crossed ankles and rest his or her head in the lap of the parent. This allows the parent to see in the mouth with adequate lighting. Use doll to demonstrate both methods.
The practice we recommend includes wiping a baby’s gums with a soft cloth before teeth erupt. Use an appropriate sized toothbrush with smear of fluoridated toothpaste, brushing all tooth surfaces. Remember those areas that are most likely to decay first and show them to the parent so they can also watch for early signs of demineralization. Have the child spit out the toothpaste and not rinse the mouth with water afterward. This method allows the teeth to bathe in fluoride after brushing. Young children do not always spit out their toothpaste, so it is important to use just a very small amount of toothpaste. We recognize that there is confusing information about when to start using fluoridated toothpaste, so we have created a cheat sheet that you may use. It is recommended by ADA, AAPD and AAP that children at high risk for caries use fluoridated toothpaste when the first tooth erupts.
Parents should be consistent with brushing before bed and after breakfast, but brushing at night time is most important if the parent will only commit to once daily. Brush all surfaces of the teeth, lifting the lip to ensure plaque removal at the gum line. Young children have difficulty brushing all surfaces, so daily supervision is important. Parents should also keep toothpaste tubes out of reach of small children. Ingesting large amounts of fluoridated toothpaste is harmful and can cause toxicity.
When teaching toothbrushing techniques, it is helpful to use the tell-show-do method to ensure comprehension.
*It is recommended by ASTDD, AAPD and AAP that children at high risk for caries use fluoridated toothpaste when the first tooth erupts. 33

34. Oral hygiene Age 6 years through adults
Brush 2X/day with pea-sized amount of fluoridated toothpaste
Brush for 2 minutes at least once daily- use a timer if needed
Spit and don’t rinse
Use fluoridated mouthwash in addition to brushing, preferably mid-day
Clean between teeth daily with floss or toothpicks to keep plaque levels low, particularly adults.
Blah-de-blah, go thru these
When teaching tooth brushing techniques, it is helpful to use the tell-show-do method to ensure comprehension.
Pregnant women can become nauseous while brushing
Avoid pushing toothbrush against tongue
Use fluoridated mouth rinse more frequently
Rinse with fluoridated mouth rinse after vomiting 34

35. Adapted from the Washington Dental Service Foundation
Sources of fluoride
Systemic
Water fluoridation
Fluoride supplements
Fluoridated bottled water
Topical
Fluoride toothpastes
Fluoride varnish
Fluoride rinses
Gels, foams
Fluoride is one of those topics that can be confusing to people. There are two main ways to strengthen the teeth with fluoride. Systemic fluoride helps strengthen the teeth as they are forming, from the inside out. Topical fluoride makes the outer layer of the enamel stronger and more resistant to plaque and acids in our mouth which cause caries. Systemic fluoride is very low dose fluoride. Topical fluoride can be low dose, like the amount that is in toothpaste, or even fluoridated water as it flows over the teeth. Or it can be higher dose fluoride, like what is used in fluoride varnish which is painted on the teeth.
As you can see, there are many ways that a person can get fluoride. So if a person is against water fluoridation, there are other alternatives.
Adapted from the Washington Dental Service Foundation 35

36. Fluoride varnish Effective Safe Easy 30% - 69% decrease in caries
Photo: ICOHP, WDSF
Effective
30% - 69% decrease in caries
Safe
No preservatives, BPA, dyes
No evidence-based contraindications
Easy
Takes 30 seconds to apply
First Tooth encourages the intervention of fluoride varnish because it is the most effective fluoride intervention for caries reduction. When used at least twice a year, fluoride varnish has been shown to reduce caries by 30% - 69% in primary teeth.
Fluoride varnish is safe. There are no preservatives, BPA or added dyes. Fluoride varnish is not absorbed through the stomach walls, so it does not compound the mount of fluoride someone may be receiving through toothpaste or water. This is also why it does not cause toxicity even though it slowly gets ingested throughout the day.
Applying fluoride varnish is easily applied, often at HS school. Many HS schools have expanded practice Hyg come to the school for screenings and fluoride varnish. Is this done at your HS school?
Use of fluoride varnish for caries prevention has been endorsed by the ADA, but remains an “off-label” use of the product, because it is not cleared for marketing by FDA for this purpose.

37. Fluoride varnish at WIC or Head Start
Most Head Start schools have a dental provider come to the school and provide screenings and exams as well as fluoride varnish. Here is an example of the application of fluoride varnish in the WIC setting, but looks similar to how it is done in school.
Although you as educators will not be doing the oral exam or fluoride varnish application, I wanted to show you what to expect when the dental professionals come in to your clinics, or when they go to their first dental visit. This will help you be prepared to answer any questions your parents may have prior to the dental day.

38. Post varnish instructions
Child may take a drink of water immediately
No brushing until the next day
Can skip fluoride supplement for the day
Ok to drink as usual
Avoid hard, crunchy and sticky foods the rest of the day
Advise caregiver teeth may be yellow for a day (based on varnish)
Repeat every 3 months for children at high risk for caries
Fluoride varnish instructions are different than fluoride treatments many of us had as children. The varnish sets with saliva and water, so it isn’t necessary to wait 30 minutes before drinking or eating. However, keep in mind that hard, crunchy foods or hot beverages may wear the varnish off faster. So encourage cool drinks and soft diet for the rest of the day.
The varnish ideally should be on the teeth for several hours, and it is ok to encourage the parent to wait on toothbrushing until the next day. Fluoride varnish should be applied 4 times a year for children at high risk for caries and up to 2 times a year for children at moderate risk for caries. Be sure to provide a copy of the take-home instructions, which is available for download in English, Spanish and several other languages on the First Tooth website.
You will not personally be providing the fluoride varnish, but it is good information if this service is provided at your school/child care facility.
Used with permission by the Washington Dental Service Foundation 38

39. Tips for educating children
and families
Lastly, lets go through some specific ways to show the parent how to brush, and tricks to show if the child refuses.

40. Treatable
Parents/caregivers must take an active role in their child’s oral health. Cleaning the teeth and providing healthy food is the parent’s job in helping the child have a healthy mouth
Intervention with fluoride varnish can reverse early stages of caries.
Early access to a dental home is important, including a regular maintenance schedule.
You will need to help parents understand that their involvement is key to managing their child’s risk of oral disease. Remind them that caries is preventable and treatable! Success in treating early childhood caries happens when caregivers understand that they are responsible to take an active role in preventing disease by changing and improving daily oral hygiene and dietary behaviors.
In addition, having the intervention of fluoride varnish at the early stages of decay can reverse the decay process and decrease the chance of more expensive and invasive dental treatment later. Partnering with a community health center, dental care organization, or CCO to provide these services can be a great partnership. Marion County is an example of a WIC program that has a dental hygienist on a regular basis to provide services and help families access a dental home.
Lastly, accessing a dental home early on can decrease the prevalence of severe early childhood caries by careful management of oral health habits and disease progression. Once a child is established in a dental home, the dental home will be responsible for providing fluoride varnish. The medical provider or WIC consultant should reiterate the importance of good oral hygiene and regular dental visits.

41. Show the parent how to brush
Utilize overhead lighting in bathroom
Lift the lip to brush at gumline and look for white spot lesions
Use short strokes to slowly scrub the teeth
Use a sequence to make sure no areas are missed
Brush tongue to remove germs on tongue
What is the process for brushing at your school? If you make sure the child gets their teeth brushed at your HS or child care facility, you will know they are getting their teeth very clean at least once a day. When brushing kids teeth at school, stand behind them and have them open so that you can use the overhead light to see clearly.
DEMONSTRATE WITH DOLL
Demonstrate for the parent tips for the parent to use at home. If the child is seated in the crossed legs of the parent and laying her head into the parent, This allows them to use the overhead lights to see, and allows the parent to see inside the child’s mouth.
Using clean fingers or a toothbrush, lift the lip to see all of the teeth, at the gumline and in the grooves of all teeth present.
Use short scrubbing strokes to clean the teeth of plaque and food debris.
It is best to use a consistent pattern to brushing to ensure no areas are missed. For instance, start in the UR corner, brush all the outsides of the upper teeth, then the insides of the upper teeth, then the biting surfaces. Then do the same on the bottom teeth, ending with brushing the tongue, which harbors bacteria. 41

42. Tricks if the child refuses
Use toothpaste that the child likes (bubble gum or berry flavored)
Use silly songs to engage the child
Have child brush parent’s teeth first
Establish patterns which cannot be changed, like washing hands before dinner
Engage older children to model good brushing behavior for younger children
It sometimes takes special tricks to engage a child in brushing habits. There are many different flavors of toothpaste, so make sure the child likes the flavor. (Always check to see that it has fluoride in it. Children at high risk of decay need fluoridated toothpaste as soon as their first teeth erupt!)
Singing songs can help the child know how long it will take (change the words to “mary had a little lamb” or other song that takes the correct amount of time to adequately brush all surfaces.)
Let the child “check” and brush the parent’s teeth first.
Remind parent that brushing is a habit like other habits which cannot be missed (washing hands, saying thank you, etc.)
Engage older siblings to help. It will remind the older sibling to brush, and it will be more fun if there are two kids brushing at the same time. 42

43. Other interventions for ECC
Interim Therapeutic Restorations- ITR
Stabilizes and treats some caries
Minimizes fear for child and parent
No anesthetic is needed, quick procedure
Silver Nitrate/Silver Diamide Fluoride
Used by some dentists to treat infection
Initially turns infection black, but follow up care includes tooth colored filling
In the past considered controversial, the use of interim therapeutic restorations has become more commonplace in the stabilization of early childhood caries. The American Association of Pediatric Dentistry recommends ITR to restore teeth and prevent caries in young patients, children with special needs, uncooperative patients or in situations where traditional restorations are not feasible.
With little to no discomfort, early to moderate ECC can be stabilized in a manner of minutes, decreasing the need for referral and extensive hospital-based dentistry.
Another intervention used by some dentists is Silver Nitrate or silver diamide fluoride which was recently made available in the US
Silver nitrate/diamide fluoride treats the infection, turning the infected area black. Usually there are follow up visits that could include removing the black area and restoring with tooth colored materials.
If someone wants more information on Silver Nitrate/silver diamide fluoride, and the local providers use silver nitrate, have the local provider supply this information.
**since silver nitrate is not yet considered “best practice” and “evidence based” we cannot support or criticize it’s use when wearing our FT hat. Please refrain from making any judgement yay or nay on silver nitrate, but offer to provide contact information of a provider who uses it to give the information. Or, if it is your office, come back at a different time with your “office hat” on.
Additionally, as more “best practice” methods become available, we will provide that information. 43 43

44. Referrals And Resources
Are there any questions before we move on to the next module?
Time to move on to how early childhood caries prevention services can be implemented.

45. Local resources and collaboration
As advocates for your clients, you probably already know how to access dental and medical providers, and encourage utilization of those providers.
Keep in contact with referral sources to establish good working relationships and to maintain an accurate referral list.
As advocates for your families, you may already have great referral systems in place for dental care. Are making timely dental referrals easy for you at WIC? If not, what sort of resources could we provide to help make this easier?
It may be important to make phone calls or personal visits to local referral sources to maintain an accurate list, as often these change frequently.
The CCO transformation of health care has made keeping up to date on OHP challenging. Do you have a contact person whom you can call if you have questions?
(Provide additional assistance if needed, even if it is the following day) 45

46. You play a huge role in preventing dental disease!!
Take home messages
You play a huge role in preventing dental disease!!
Primary/baby teeth are important for the development of the child
Understanding the disease helps you advocate for the health of your families
Early childhood caries can be prevented and treated
Pregnant women need access to dental services
Support efforts to provide preventive services to the children you serve
As nutrition consultants, you can play a very important role in preventing early childhood caries. Understanding early childhood caries disease will help you better educate your clients and improve their health outcomes. By encouraging good nutrition and oral hygiene habits, you will help influence lifetime nutrition and health behaviors.
You can also advocate for pregnant women to access dental services while they are pregnant, decrease their bacterial load, and help provide a healthier environment for their children.
Be a supporter and advocate for the preventative services offered to your clients, encouraging them and guiding them to utilize the services available. 46

47. “First Tooth” training and technical assistance contacts
Karen Hall, RDH EPDH
First Tooth trainer/technical assistance or
You can also access our website for materials
First Tooth Website
Change names!!!!! 47

48. Questions? Please fill out the training feedback form
Are there any questions?
Please fill out the training feedback form

49. Thank you!
Oregon Oral Health Coalition’s Early Childhood Caries Prevention Committee
“First Tooth” Advisory Group
Washington Dental Service Foundation
American Academy of Pediatrics