1. Oral Health in Early Education and Care
Implementing 606 CMR 7.11(11)(d)

2. This presentation was informed by materials provided by the:
BEST Oral Health (Bringing early Education, Screening, Treatment), a Program of Partners For A Healthier Community
Cavity Free Kids: Oral Health for Children in Child Care (the Washington Dental Service Foundation)

3. Tooth Brushing in Child Care
…is not new for many programs! Head Start programs and many others have been successfully brushing teeth for years without an increase in childhood illness or infection. For some children, this has been their first exposure to tooth brushing; and it has led some families to adopt new and better oral health routines at home.

4. 606 CMR 7.11(11)(d)
Educators must assist children in brushing their teeth when children:
are in care for more than four hours, or
consume a meal
Educators must assist children in brushing their teeth whenever they are in care for more than four hours, or whenever they consume a meal while in care.

5. Why Tooth Brushing in Child Care?
Dental Caries (tooth decay) is the most common chronic disease of childhood
Causes pain, sickness and mortality
Inhibits learning, speech and eating
Is almost entirely preventable!
Dental caries (tooth decay) is five times more common than asthma. If untreated, dental caries results in cavities, pain, infection and, in some instances, devastating consequences for a child’s overall health, including sickness and mortality. Untreated dental caries can inhibit learning, speech, and eating, leading to problems in school and poor nutrition. Dental caries and oral disease are almost entirely preventable.

6. Massachusetts Children Suffer!
25% of kindergarten children
40% of 3rd graders
30% of 6th graders
1/3 to 1/2 goes untreated!
A study conducted in 2003 found that a significant proportion of Massachusetts’ children suffer from dental caries, and many of our youngest children start school with dental disease. More than one-in-four kindergarten children – about 19,130 children– had evidence of dental decay, with nearly 10,000 of those children having untreated dental decay. More than 40% of 3rd grade children – about 29,110 students – had evidence of dental decay, and about 12,400 of those children had untreated decay. About one-third of 6th grade adolescents – about 24,575 students – had been affected by dental caries, and nearly 8,000 of those adolescents had untreated decay.
51 million school hours per year are lost due to oral health problems.
From: Oral Health in America: A Report of the Surgeon General
The Oral Health of Massachusetts’ Children, Catalyst Institute, January 2008

7. Very Young Children Suffer from dental decay
6% of 1 year olds
22% OF 2 YEAR OLDS
35% OF 3 YEAR OLDS
48% OF 4 YEAR OLDS
Too many young children suffer from dental caries. It may begin in part by putting juice in the baby bottle, letting the child go to bed at night with a bottle of milk or formula, letting the child “graze” with a bottle or sippy cup. Of course, sweet snacks contribute their share of the problem!
Even close contact with a parent who has dental caries may increase the child’s risk of infection from the bacterium streptococcus mutans.

8. Low Income Children Suffer Most: nearly 12 times more lost school days than children from higher income families 
Children from families with low incomes had nearly 12 times as many lost school days because of dental problems as did children from families with higher incomes.
Dental caries begins with white spots on the teeth, usually close to the gums. This is a sign of mineral loss. If untreated, the decay progresses to brown spots around the gum line, and ultimately eats away at the teeth and can lead to serious, systemic infections.

9. Early Childhood Caries (ECC)
Bacteria
A bacterium (called streptococcus mutans) breaks down food into acids that eat away at the minerals in the tooth. ECC affects teeth that erupt first, at about six months. These teeth have a much thinner layer of enamel than adult teeth, and are less protected by saliva.
Sugar

10. Limit the frequency of sugar intake
INTERVENTIONS
Improve diet
Limit the frequency of sugar intake
Remove dental plaque bacteria with tooth brushing
Provide added fluoride
Seek preventive care
To reduce the disease of early childhood caries, we can:
Decrease the number of times per day that children consume foods or drinks high in sugar and carbohydrates. Acids produced by bacteria after sugar intake persists for 20 – 40 minutes.
Limit juice to 4-6 ozs per day
Mechanically remove dental plaque by brushing
Use fluoride toothpaste to restore minerals to the tooth (for preschoolers)
Arrowed interventions can be done in child care!

11. There are many different opinions…
Fruit Flavored?
Rinse?
No Fluoride!
Tooth Paste?
Fluoride?
There are many different opinions…
Spit?
You will hear differences of opinion among experts involved in oral health, involving everything from the flavor of the tooth paste to when and how kids should spit. EEC regulations do not address these details.
Don’t Spit!
Don’t Rinse!
Mint Flavored?

12. Experts Agree: Tooth Brushing Reduces Dental Caries.
EEC is focused on the big picture. Any brushing (done under proper conditions for sanitation and infection control) is better than no brushing..with or without toothpaste, with or without fluoride, with or without rinsing and spitting.

13. Tooth Brushing Techniques
Wipe an infant’s gums with a clean, damp cloth after feeding.
Oral health should start with infants. Wiping the gums with a clean, damp cloth removes sugars that feed bacteria. Once teeth erupt, it is important to brush teeth with plain water twice per day.

14. Proper Labeling Child’s name Date of issue Elijah 3/3/09
Colin 2/2/09
Elijah 3/3/09
Aliyah 3/7/09
Mike J. 2/2/09
Children must have individual, labeled toothbrushes. Toothbrushes should be replaced every 3 or 4 months, or sooner if the bristles appear worn and/or a child experiences illness.
Tooth brushes should not be disinfected with liquids or run through dishwashers, microwaves or ultraviolet devices because they have not been proven effective, and may damage tooth brushes.
To prevent the spread of germs, educators should retrieve and give each child his/her tooth brush when it is time to brush.

15. Tooth Brushing Techniques: begin brushing once the first tooth erupts
Once the first tooth erupts, tooth brushing should begin. For an infant or young toddler, hold the child on your lap facing you and brush the teeth with a circular motion, being sure to reach close to the gums. Initially you may use water only, or use a small smear of tooth paste on a soft bristled brush. Children at risk for decay may need to use a small amount of fluoride toothpaste, if recommended by the child’s dentist. The child does not need to rinse or “spit” after brushing.
(Note: in the child care program, the educator should wear gloves when assisting infants and toddlers in brushing.)

16. Tooth Brushing Techniques
Children over two should use a pea-sized dab of toothpaste, and can rinse and spit (when able).
Children over 2 years old need only a small dab
of tooth paste.

17. Distributing Tooth Paste
To prevent the spread of germs, tooth paste should not be distributed directly from the tube to a child’s tooth brush. An educator may distribute small “dabs” of tooth paste onto a paper plate, and then take a dab of toothpaste from the plate with each child’s brush.
Alternatively, programs may choose to distribute a small dab of toothpaste on the bottom or on the side of each child’s cup.
without spreading germs

18. Provide Water to Rinse the Brush
After the toothpaste is on the brush, a small amount of water can be poured into each child’s cup. Providing a paper towel is also a good idea and helps minimize any mess.
…and a paper towel for clean-up.

19. Brush Teeth and Tongue! Spend about 2 minutes brushing.
Using a circular motion and holding a soft tooth brush at a 45% angle to the teeth and gums, the child should spend about two minutes brushing his teeth. He should brush in one area to the count of 5, and then move on to the next. They should end by brushing the tongue…germs like to hide there!
Spend about 2 minutes brushing.

20. Rinse the Brush …and rinse your mouth & spit into cup if you wish.
After brushing, the tooth brush should be rinsed. Depending on your brushing routine, the child may rinse his brush in the cup of water. The child does not need to rinse his mouth, but may want to use the cup to take a sip of water, swish and spit back into the cup.
…and rinse your mouth & spit into cup if you wish.

21. Cleaning Up Dry off the brush…
The child can wipe the brush on the paper towel,
Dry off the brush…

22. Almost done… Put the paper towel in the cup….
Put the towel in the cup…
Put the paper towel in the cup….

23. Done! Throw away the cup and the paper towel.
And throw the cup away. If the child is too young to do this independently, or if educators prefer, they can collect and rinse tooth brushes one at a time (as children finish brushing), and then put the tooth brushes away to dry in a safe and sanitary manner.
Throw away the cup and the paper towel.

24. Proper Storage Educators put tooth brushes away Open to the air
Not touching each other
No disinfectant cleaners
To avoid the spread of germs after brushing educators should collect children’s tooth brushes and put them in their storage racks in a safe and sanitary location, making sure that no child’s tooth brush touches another. Tooth brushes must be stored open to the air to allow for drying between uses, but in a way that keeps them clean. Tooth brush racks can be hand made using egg cartons, or can be purchased from suppliers like Lakeshore.

25. Proper Maintenance
Toothbrushes should be replaced every 3 or 4 months, or sooner if the bristles appear worn and/or a child experiences illness.
Tooth brushes should not be disinfected with liquids or run through dishwashers, microwaves or ultraviolet devices because they have not been proven effective, and may damage tooth brushes.
Recommendation: replace after illness and when worn,
at least every three months.

26. Proper Supplies
Toothpaste
Toothpaste chosen for young children should be a general mint flavor. Using fruity flavors encourages children to eat the toothpaste, which is not advised. It is important to know if a child has any possible allergies to ingredients or additives in toothpaste. For that reason, educators must obtain parental consent for tooth brushing when using toothpaste. (In that case, parents may prefer to provide their own tooth paste, or programs may prefer brushing without tooth paste.) When choosing toothpaste, programs should look for two important things:
Sodium Fluoride as an active ingredient
The American Dental Association (ADA) Seal of Approval
Recommended: mint flavored, ADA approved, sodium fluoride (over 2 years)

27. Proper supervision is always required!
Safety First
Toothpaste is intended to provide a topical source of fluoride. It is NOT supposed to be swallowed by the child because swallowing too much fluoride might cause a child under 10 to have a defect called fluorosis in his or her growing adult teeth. As always, proper supervision is required.
Proper supervision is always required!

28. Sanitizing and Disinfecting
EEC regulations require that tables be cleaned and disinfected before and after each meal. Likewise, tables should be cleaned and disinfected after brushing is done at the table. As always, sinks and faucets must be monitored for cleanliness and washed and disinfected at least daily.
After brushing, clean and sanitize tables and/or sinks.

29. For additional information, see other resources
posted on the EEC regulations support page at: 29