GrowingHealthySmiles

InTheChildCareSetting

ImplementingaToothBrushingProgramtoPromoteOralHealthand

PreventToothDecay

OfficeofOralHealth

MassachusettsDepartmentofPublicHealthNovember2009

Withconcernsabouttheincreaseindentaldisease(toothdecay)amongyoungchildren, the Massachusetts DepartmentofEarlyEducationandCare (EEC)recentlyadopted a newregulation for childcaresettings,number606CMR7.11(11)(d),topromoteoral healthandpreventtoothdecay.

Thisguidehasbeendevelopedtohelpearlyeducationandcareprograms.Thisresourcewillhelpchildcareworkers:

  • Understandtheproblemofdentaldiseaseinchildren;
  • Understandthecauseoftoothdecayandhowtopreventit;
  • Learnstrategiestoeffectivelyimplement a toothbrushingprogramin a childcaresetting.

Theguideisorganizedinto3sections:

  • Section 1
  • Reviewsthecauses,risk-factors, andpreventionstrategiesfortoothdecay
  • Section 2
  • Discussestheimportanceoftoothbrushingandprovidestipsonsafelyimplementing a toothbrushingprogram,including:

YToothbrushinginstructions

YSuppliesneeded

YSafehandlingandstorageoftoothbrushesandtoothpaste

YOrganizationofthetoothbrushingactivityandstaffsupervision

YSampleletterandfactsheetforparents/caregivers

  • Section 3

o

Offers resources for additional information on other school and grouptoothbrushingprogramsandoralhealth teachingtools/lessonsforyoungchildren

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HowDoesToothDecayHappen?

In most children, primary (baby)teethbegintoeruptataround 6 monthsofage.Oncethefirsttootherupts, a childisat-riskfortoothdecay.Infact,toothdecayisthemostcommonchronicdiseaseamongchildren.Toothdecayordentalcavitiesisaninfectiousdisease,meaningthebacteriathatcausetoothdecaycanspreadfrompersontoperson.Thediseasestartsaftereatingordrinkingsomethingwithstarchorsugar.Bacteria(germs)inthemouth“eat”thesecarbohydrates,whichallowthemtogrowandcollecttogetheron thetooth.This collectionofbacteriaiscalleddentalplaque.Thebacteriaindentalplaquecontinuetoeatcarbohydratesandproduceacids.Theseacidsweakenthetoothand ahole,or a “cavity,”isformed.

TheProcessofToothDecayFormation

Sugar/StarchBacteria (Germs) in Plaque

Healthy Tooth

WhyShouldYOUCareAboutToothDecay?

Babyteethareimportant!Whenveryyoungchildrendeveloptoothdecayitcanhurtmorethanjusttheirsmile;nutrition,socialization,self-esteem development,well-being,andthedevelopmentanderuptionoftheiradult(permanent)teethcanallbeimpactednegatively.Furthermore,havingtoothdecayinearlychildhoodputsthechildat-riskfortoothdecayinadulthood.NochildshouldexperiencetheseproblemsbecauseTOOTHDECAYISPREVENTABLE.Withyourhelpenforcingthenewtoothbrushingregulations,childreninyour carewillhave a lesserchanceofsufferingfromthisdisease.

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WhatDoesToothDecayLookLike?

Thefirstsignoftoothdecayis a whiteandchalkyspotonthetooth,oftenonthefrontteethnearthegumline.At thisstage,thedentalcariesprocesscanbestoppedandthetoothcanbehealedifmineralslikefluorideindrinkingwaterandtoothpasteareusedregularly;andifthechild’sdietischangedtolimitfoodsanddrinkswith a lotofsugar,aswellascarbohydrates.

Iftheteetharen’tkept clean,theydon’treceiveenoughfluoride,andsugarisn’tlimitedinthediet,eventually a holeformsinthetooth’s

enamel or outer surface. Once the toothhas a holeitmustbetreatedby a dentist.Thedentistwillremovetheinfectedpartofthetoothandfillthehole.

If a cavityisnottreated,theinfectionwillcontinuetoweakenthetooth.Ifitspreadstotheinnermostpartofthetoothwherethebloodvesselsandnervesarelocated,thetoothcanbecomeverypainfulandtheinfectioncanspreadtootherparts ofthebody.Thissevereinfectionmustbetreatedimmediately.

WhatFactorsAffecttheToothDecayProcess?

Thedemineralizationandremineralizationprocessisaffectedbyseveralfactors.Someofthesefactorsinclude:

  • Saliva
  • Oralhygienebehaviors
  • Fluorideexposure
  • Diet
  • Medicine
  • General health

Allpeoplewithteeth(childrenandadults)areat-riskfordevelopingtoothdecay;howeverprimary(baby)teethhave a muchthinnerlayerofenamelcomparedtoadult teeth. Therefore,youngchildrenaremoreat-riskfortoothdecay,whichusuallyprogressesquickerthanitdoesin adult teeth.

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Fortunately,TOOTHDECAYCANBEPREVENTED.Inthechildcaresetting,youcanhelppreventtoothdecaybyencouraging two importantpreventionstrategies:

1.Mechanically remove dentalplaquebacteriawith a toothbrush,using a verysmallsmear or pea-sized amount offluoridetoothpastetostrengthenthetooth.

2.Decreasethe frequency (number of times per day) childrenconsumefoods/drinkshighinsugar and carbohydrates.Childrenshouldnevertake a naporgotosleepatnight with food or milk/juice.

~6 oz

WhyisToothbrushingImportant?

~4 oz

AccordingtotheCentersforDiseaseControlandPrevention(CDC),“Whendoneroutinelyandproperly,toothbrushingcanreducetheamountofplaquewhichcontainsthebacteriaassociatedwithgumdiseaseandtoothdecay,aswellasprovidethecavity-preventingbenefitsof fluoride.”Toothbrushingisimportantfortwomajorreasons:

1.Brushingteethremovesplaque,whichcontainstoothdecaycausinggerms.Plaquetends to form after meals or drinks that containanysugarorcarbohydrates.Brushingaftereating/drinkingcanremoveandcontrolthegrowthofplaquebacteria(germs)thatforms on the teeth.

2.Brushing with toothpaste thatcontainsfluoridemakesthetoothstrongerandlessat -risk for developingtooth decay.

ImplementingaToothBrushingProgram

Toimplement a toothbrushingprogram,youwillneedtoconsiderseveralthings:

1.Toothbrushinginstructions;

2.Managingandstoringsupplies;

3.Infectioncontrolandorganizationoftoothbrushingactivity;

4.Staff involvement and supervision of children; and

5.Informingparents/caregiversabouttheprogramandtheprevention of tooth decay.

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  1. ToothbrushingInstructions

Upuntilaboutage8,mostchildrendonothavethefinemotorskillstoindependentlybrushtheirteetheffectively, so they will needyourhelp.Childrenwillneedsupervisionandassistanceinordertobrushsafely,correctly,andthoroughly.

Usethediagramontherighttohelpchildrenbrushtheirteeththeproperway. It is especially importanttobrushallteethsurfacesbygentlymovingthebrushinsmallcirclesto removeplaqueandfooddebris, and deliver fluoride fromthetoothpaste.Asa childgetsolder,theytendtogettoothdecayinthemolarorlargebackteeth.Besuretoremindallchildrentobrushtheseareas,too.Also,don’tforgettobrushthetongue.

ImportantInstructionsforBrushingwithFluorideToothpaste:

  • Childrenunder 2years of age should
  • Use a small smear offluoridetoothpaste;
  • Spit italloutinthesink;and
  • NOT rinse with water after brushing.
  • Childrenover 2 yearsofage should
  • Use a pea-sizedamountoffluoridetoothpaste;
  • Spit italloutinthesink;and
  • Rinsewith a littletapwaterprovidedindisposablepapercups.Cupsshouldnotbesharedorusedagain,andshouldbethrown away afteruse.

Image courtesyof:

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  1. ManagingSupplies

First,youwillneedtodesignatestaffmemberswhowill be responsibleformanagingsupplyinventory,ordering/purchasing,storage,anddistribution.Youwillneedtothinkaboutwheresupplieswillbesafelystoredandhowtheywillbedistributed to children.

Yourinventoryofsupplieswillvarydependingonthenumberofchildrenthatattendyourchild care facility. It is recommended that suppliesareorderedandpurchasedbythechildcarefacility.If a programreliesoneachchild’sfamilytoprovidetoothbrushesortoothpaste,theprogramshouldhaveextrasuppliesonhandforchildrenwhoforgettobringthemfromhome.

TheMandatorySuppliesInclude:

  • Toothbrushes
  • FluorideToothpaste
  • ToothbrushLabelsandStorageSystems
  • DisposableCupsforRinsing

Toothbrushes

  • Toothbrushlabeling

Eachchildshouldhaveanageappropriatetoothbrushlabeled with hisor her full name and the date thetoothbrush was giventothechild.Thiscanbedoneusingmaskingtapeand a permanentmarkerorwaterproof printable labels/photopaper.Donotallowchildrentoshareor borrow toothbrushes.

  • Choosinganageappropriatetoothbrush

Toothbrushesaremadefordifferentagesbasedon a child’smotorskillsandgrowth/developmentalstage.Infantbrushesusuallyhave a verysmalltoothbrushhead(about 1 inchby ½ inch) with extra soft bristles.

As a childages,hisorhermouth growsandmoreteetherupt,so alargertoothbrushheadisneeded. Forallchildrenandadults,onlytoothbrusheswithsoft bristlesshouldbeused.Mediumandhardbristlescandamagethegumsandteeth.Manualbrushesshouldbeused, not electric brushes.

  • Orderingtoothbrushes

Suppliersoforalcareproductscanhelpyoudeterminewhattoothbrushestopurchasebasedonthenumberofchildren you care for and their ages.

Toothbrushesofallsizesshouldbepurchasedinbulksoreplacementsarereadilyavailable.

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ReplacingChildren’sToothbrushes

AccordingtotheCentersforDiseaseControlandPrevention(CDC),soakingtoothbrushesindisinfectingsolutionsormouthwashisNOTrecommendedbecauseitmayactuallyspreadgerms.Usingdishwashers,microwaves,orultravioletdevicestodisinfecttoothbrushesisalsonotrecommendedbecausetheycandamagetoothbrushesandarenotproveneffective.

Toothbrush Storage Systems

Thistoothbrushholderismadeusinganempty egg carton.

  • Turnthecartonupsidedownandpokesmallholesintoeachcompartment.
  • Fit a toothbrushintoeachcompartment.Thetoothbrusheswillbeupright,nottouchingeachother,andabletodryintheopenair.
  • Make a newholderusingthesamemethodwhenitisobviouslysoiled ordegrading.

TheMassachusettsDepartmentofPublicHealthdoesnotendorseanyparticularcompanyorproduct;however,toassistyouonpage13,wehavelistedsomeofresources to purchase oral health related items, such as the toothbrush storagesystempicturedontheright.

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Toothpaste

Toothpastechosenforyoungchildrenshouldbe ageneral mint flavor. Using fruity flavorsencourageschildrentoeatthetoothpaste,which is not advised. It is also important toknowif a childhasanypossibleallergiestoingredientsoradditivesintoothpaste.Whenchoosing a brandoftoothpaste,lookfortwo

important things:

1.SodiumFluorideasanactiveingredient

2.TheAmericanDentalAssociation(ADA)SealofApproval

Toothpasteshouldalwaysbestoredinalockedcabinet,awayfromchildren’sreach.Onlyachildcareworker,oradult,shouldhaveaccesstoandhandlethefluoridetoothpaste.

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3.MaintainingInfectionControl

Toothbrushescanbecomecontaminatedwithbacteria,blood,saliva,food,andtoothpasteafterbrushing.Diseasetransmissionisrare,butallprecautionsshouldbetakentoensureproperstorageandhandlingoftoothbrushes and toothpaste to preventcrosscontaminationofgerms.

DistributingToothpaste

  • Deliveringtoothpastedirectlyfromthetoothpaste container onto all children’sbrushescanspreadgerms.Topreventcrosscontamination,dispense smears orpea-sizedamountsoftoothpasteforeachchildonto a largepieceofwaxpaper,paperplate, or bottom of therinsingcup.Fromhere, a singleservingoftoothpastecanbeplacedontoeachchild’stoothbrush.

StoringToothbrushes

  • Afterchildrenfinishbrushing,theyshouldrinsetheirtoothbrushesthoroughlywithtapwater.TheCDCrecommendsthattoothbrushesbestoredinanopencontainerthatallowsthemtostandupright and out of contact with otherchildren’sbrushes.Aspreviouslymentionedonpage7,youcanpurchase a toothbrushstoragesystemoreasilymakeoneusingeverydayhouseholditems.Toothbrushesshouldbestoredinanopenarea,butawayfromthereachofchildren.

AssistingChildrenwithTooth Brushing and Clean-Up

Childrenshouldbesupervisedtopreventaccidentalspittingoneachother'sarms,handsandtoothbrushes.Afterassisting a childwithtoothbrushing,the caregivers should washtheirhandsthoroughlywithsoapandwaterbeforeassistinganotherchild.Childrenshouldalsowashtheirhandswithsoapafterbrushing.Besuretocleanthesinkareaasyouwouldnormally;thereisnoneedforspecialclean-up.

ReplacingToothbrushes

A toothbrushshouldbethrownawayandreplacedwith a newonewhen:

1.Thebristleslookfrayedandworn;

2.A childhasbeenillwith a cold,flu,orbacterialinfection;and/or

3.Thetoothbrushis 3 monthsold.

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  1. StaffInvolvementandSupervision

Dependingontheagegroupofchildrenand the numberofchildrenunderyoursupervision,youmightneedmore stafftohelpyoutoassistwithbrushingchildren’steeth.Eachchildshouldhavehelpbrushinghisorherteethuntilaboutage8.ChildrenMUSTbewellsupervisedduringtoothbrushingwithfluoridetoothpaste,andshouldnotbeleftunattendedorbeallowedtodispensethetoothpastealone.

Itisrecommendedthatyouandyourstaffdevelop a specificplan to implement theEECtoothbrushingregulation.Communicate withotherchildcarefacilitiestogettipsandadviceonhowothersareimplementing a toothbrushingprogram in your

localarea.Itmightbehelpfultodesignate specific tasks to each staff member.

Sometaskscaninclude:

  • Keepingtrackofpurchasing toothbrushes and toothpaste
  • Makingand/orpurchasingtoothbrushlabelsandstoragedevices
  • Organizingchildrenintwogroups:underage 2 andoverage2;andobservingthem/helpingduringbrushing
  • Distributingtoothpastetochildrenintwogroups(underage 2 gets a “smear”oftoothpasteandoverage 2 gets a “pea-sized”amount),andensuringitislockedupandsafelystoredafteruse
  • Helpingchildrenoverage 2 torinsewithwater
  • Helpingchildrengettheirbrushinto their appropriate storage space
  1. CommunicatingwithParentsAboutYourToothbrushingProgram

Itwillbeimportanttoinformyourchildren’sparents/caregiversaboutyournewtoothbrushingprogram.Youcouldsend a notehomewitheachchildoryoucouldhaveaninformationalmeetingfortheparentsatthechildcarefacility.ParentsshouldunderstandWHYthisnewpolicyisbeing implemented.Once theyunderstandthepolicyistohelppreventtoothdecay,theymaybemorewillingtostart doing moreoral healthpreventionactivities at home. The letter and fact sheetonthenexttwopagesareexamplesofdocumentsyoucouldeditandusetoinform and educate parentsaboutthenewtoothbrushingprogram.Youcanencourageparentsto:

  • Forinfants,wipethebaby’smouthwith a wetclothafterfeeding(evenbeforeteetherupt!).
  • Beginanoralhygienebrushing routine as soon as the firsttootheruptsinthechild’smouth.
  • Reinforcetoothbrushingandlow-sugar snacks/meals at home.
  • Packhealthylow-sugarmeals,andprovidewaterinsteadofsodaorsugaryjuicestodrink
  • Talk to their child’s doctor or dentistaboutfluorideexposureandthepossibleneedfor fluoride supplementation.
  • Talktotheirchild’sdoctoraboutthepossible need for fluoride varnish during thewell-medicalvisits.
  • Seekearlypreventivedentalcareforallfamilymembers.

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SAMPLELETTERFORPARENTS/CAREGIVERS

Dear Parent or Caregiver:

Withconcernsabouttheincreaseintoothdecay(cavities)amongyoungchildren,theMassachusettsDepartmentofEarlyEducationandCare(EEC)recentlyadopted a newregulation for childcaresettings,number606 CMR7.11(11)(d),topromoteoralhealthandpreventtoothdecay.

Effective January2010, child careworkersmustassistchildren with brushingtheirteeth if:

1.Thechildrenareincareformorethan 4 hours,or

2.Theyhave a mealwhile in care.

Somequickfactsabouttheprogram:

•ThisprogramwillbeimplementedsafelybyfollowingtheregulationsforinfectioncontrolsetbytheU.S.Centers for Disease ControlandPrevention(CDC).

•Itwillbe a greatbenefitforyourchild,theirmouthhealthandgeneralhealth

•Childrenwillbebrushingwiththedirectsupervision of our child care staff

•ChildrenwillbeusingtoothpastewithfluorideandapprovedbytheAmericanDentalAssociation

•Childrenwillreceivenewtoothbrushesafterthreemonthsofuse,oraftertheyaresick

Ifyouhaveanyquestionsorconcerns,pleasecall

_at.

Child’s Name:

Parent/Caregiver’sName:

Signature:

Date:

Comments:

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SUGGESTEDFACTSHEETFORPARENTS/CAREGIVERS

QuickFactsAboutChildren’sOralHealth

Babyteethareveryimportant. Babyteethhelpyourchildeatandspeakcorrectly.Theyalsoholdthespacingneededforadultteethtoeventuallyerupt.If achildhastoothdecay(cavities)inchildhood,heor sheismorelikelytohavetoothdecayastheyget older.

Unfortunately,toothdecayisthemostcommonchronicdiseaseofchildren,butitdoesn’thavetobe.Tooth decayis completelypreventablebyfollowing a fewsimpleoralhygieneactivities:

•Duringinfancy,wipethechild’smouthwith awarmclothafterfeeding.

•Don’tgivechildrenanythingotherthanwatertodrink at bedtime.

•Brushteethwith a fluoride toothpaste at least 2timesperdayandflossdaily.

•Getanexamby a dentalprofessionalatleastonce a year.

•Keepeatingsugarysnacksanddrinksto aminimum.

•Drinkfluoridatedwater.

Tips on helping your child brush his or her teeth

./ Keepthefluoridetoothpasteoutofchildren’sreach,andyouputiton the brush for them:

  • Forchildrenunder 2 yearsold,putonlya “smear”oftoothpasteontheirtoothbrush.
  • Forchildrenover 2 yearsold,use a“pea-sized” amount of toothpasteonthetoothbrush.

./Helpchildrentobrushinlittlecircles,makingsuretheygetallteethsurfaces,includingtheoutside,inside,andthetopsofmolars(backteeth).

./ Makesurechildrenspitoutallofthetoothpasteintheirmouths.Childrenunderage

2 yearsshouldNOTrinseafterspitting.Childrenover 2 yearsoldshouldrinsewitha smallamountoftap water after spitting.

./ Makesurechildrenbrushtheirteethrightbeforebedtime,andtheydonoteatordrinkanythingsugaryatbedtime.

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Learnmoreaboutchildren’soralhealth

  • MassachusettsDepartmentofPublic Health Office of Oral Health
  • AssociationofStateandTerritorialDentalDirectors
  • CentersforDiseaseControlandPrevention
  • AmericanAcademyofPediatrics
  • NationalMaternalandChildOralHealthResourceCenter
  • AmericanDentalAssociation
  • AmericanDentalHygienist’sAssociation
  • AmericanAcademyofPediatricDentistry

TopurchasetoothbrushholdersliketheoneImagecourtesyof:

picturedhere,visitthesewebsites:

  • \ 017~~f%7C/Assortments/Lakeshore/ShopByCategory/science/healthnutrition.jsp

Otherhelpfulsupplies

Timers canmakebrushingteethfunforchildren.

Models ofteethandthemouthcanbegreatwaystoteachchildrenaboutoralhealth

Toreceiveanexcellentonlinetrainingonchildren’soralhealthforthechildcareworker,visittheNational Training Institute for Child Care Health Consultants(NTI):

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OfficeofOralHealthMassachusettsDepartmentofPublicHealth

250WashingtonStreet

Boston,MA02108

617-624-6074

AdditionalandrelatedinformationisalsoavailablefromtheMassachusettsDepartmentofPublicHealthOfficeofOralHealthwebsite:

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