Evaluation of the Head Start Oral Health Initiative

Chapter III: Delivery of Services

The plans that Head Start grantees developed for the Oral Health Initiative (OHI) focused largely on oral health education; preventive services; and capacity building with community, county, and state dental professionals and professional organizations. While grantees already had systems in place for providing dental exams and treatment as required by Head Start Program Performance Standards, OHI services were intended to supplement existing services, reduce the need for treatment through prevention, and increase the percentage of children and pregnant women receiving needed care. This chapter further explores the types of oral health services and activities Head Start grantees carried out in the first year of implementation. It focuses on the five main categories of activities and services grantees provided to children and families through the OHI: (1) education for parents, pregnant women, and children; (2) establishment of dental homes for children and pregnant women; (3) preventive and treatment dental care services; (4) support services; and (5) distribution of supplies. Information for this chapter comes from two main sources: (1) record-keeping system data and (2) telephone interviews conducted with grantee staff.

Oral Health Education

Grantees reported that a common barrier to dental care was the lack of education among families about the importance of oral health care for young children. According to grantee staff, many parents believed that primary teeth were unimportant because children eventually lose these teeth. In addition, many parents feared taking their children to a dentist based on their own negative or painful experiences. To overcome these barriers and promote oral health care for children, parents of children at high risk for caries should receive education that motivates them to take an active role in their children’s oral health and information that reinforces proper oral hygiene and dietary habits at home (Brown et al. 2005a; Brown et al. 2005b).

To promote attitudes and beliefs conducive to supporting healthy teeth and gums, the OHI grantees reported providing education to three key groups: (1) parents and primary caregivers, (2) pregnant women, and (3) preschool children. In addition to educational opportunities for families and children, grantees also discussed the benefits of training for staff. As described in Chapter II, grantees provided training on oral health curricula and prevention strategies to improve staff’s understanding of oral health care. This increased understanding was intended to benefit the families staff members serve, as well as improve their own oral health status.

Education for Parents

Nearly all grantees (94 percent) described parent education as a main goal or key component. In response to this goal, all grantees reported providing some type of oral health education for parents. According to the record-keeping system data, 82 percent of grantees provided some form of oral health education for parents between February and May 2007 (Table III.1). More than half of the grantees reported providing parent education through workshops (at parent meetings or special events) or home visits once a month. Through workshops and home visits together, grantees provided education to nearly 2,000 parents a month on average.

Location of Parent Education
N = 52 grantees.
	Percentage of Grantees
Parent meetings	67
Home visits	36
Workshops	17
Appointments	17
Events	15
Material Sent Home	33

Education for parents followed two main formats: (1) integration into already existing formats and (2) newly created events and workshops. Grantees that integrated educational messages about oral health into already existing formats provided education during parent meetings, home visits, and parent conferences and through materials distributed to parents, such as monthly newsletters and take-home activities from classroom curricula (see box). New formats included specially planned workshops, additional home visits from oral health professionals, educational opportunities that took place during dental appointments, and special events. For example, grantees planned events that brought together families and dental professionals, as well as trainings for parents conducted by grantee staff or a combination of grantee and community partner staff.

Educational opportunities integrated into existing avenues of contact with parents were most commonly the responsibility of home visitors and family service workers. These staff frequently received training and resources, such as curricula materials, Internet resources, and theme bags or kits containing materials and supplies. They, in turn, used the training and resources to educate parents. Grantees that offered education at special events and workshops more commonly relied on oral health specialists, health specialists, or other dental professionals to deliver messages. These staff members conducted training at specially planned events and workshops or during annual parent meetings focused on oral health. In some cases, specialized staff and professionals also conducted home visits with parents to assess oral health needs and provide individualized education. Grantees that used OHI funds to create new staff positions were more likely than grantees that used existing staff to report specialized home visits and training workshops. All grantees relied on classroom teachers, home visitors, and family service workers to reinforce oral health education with families.

Table III.1. Oral Health Education Offered to Parents and Children
		Percentage of Grantees
Offered Parent Education at Least One Month		82
Number of Months Grantees Offered Parent Education Through Workshops	0	21
	1	22
	2	25
	3	20
	4	12
Number of Months Grantees Offered Parent Education During Home Visitsa	0	23
	1	18
	2	12
	3	16
	4	29
Number of Months Parent Education Offered Through Written Materials Sent Home with Children	0	29
	1	12
	2	10
	3	23
	4	25
Offered Education for Children at Least One Month		82
Number of Months Grantees Offered Education to Children in Classrooms	0	18
	1	20
	2	4
	3	23
	4	33
Number of Months Grantees Offered Education to Children During Home Visitsa	0	45
	1	10
	2	8
	3	19
	4	18

Source: Record-keeping system data from 51 grantees, Februrary 1 to May 31, 2007.
Note: N = 51 grantees. Missing range from 0 to 2 across items because data entry was incomplete.
a Percentages based on 51 grantees; however, 22 grantees did not offer home-based services.

Topics for Education on Oral Health
N = 52 grantees.
	Percentage of Grantees
Importance of oral health	69
Skills training on dental hygiene	52
Healthy nutrition	36
Developmental milestones	23
Preparation for dental visits	21
Visual inspections of children’s teeth	23
Behaviors that threaten oral health	11

The most common educational messages delivered during trainings were on preventive care and the importance of oral health care for young children. Programs provided parents with information on prevention and early detection of dental caries, how oral health development relates to overall physical development, when and how parents should care for their children’s teeth and gums, and the importance of preventive care for all family members. Half of the grantees cited skills training on dental hygiene as a key educational message for parents. Grantees reported showing parents how to brush their children’s teeth, wipe infants’ gums, and encourage proper tooth brushing techniques with children. Information on healthy nutrition and the role of nutrition in promoting healthy teeth was included in education delivered to parents by 36 percent of grantees. Other commonly cited educational topics included the developmental milestones in oral health development; dentist visit procedures or information about what to expect at the dentist’s office; how to conduct visual inspections of children’s teeth using methods such as “Lift the Lip” (Lee et al. 1993);1 and behaviors that threaten oral health, such as the use of bottles and “sippy cups” beyond recommended ages (see box).

Education for Pregnant Women

Almost half of grantees (46 percent) provided oral health education specifically tailored to pregnant women. Information about oral health was most often delivered to pregnant women during home visits (63 percent of the grantees that offered education to pregnant women). Another third of these grantees (32 percent) conducted workshops or training classes on oral health, and about half of these were delivered in combination with education during home visits. These events were sometimes one-time trainings, while other grantees delivered a series of classes. One grantee reported conducting a training at the start of the Early Head Start program year and then a follow-up training about five months later, which is typically after women have had their babies. This format allowed the oral health coordinator to focus the first training on the importance of practicing preventive care, including dental visits, during pregnancy and the follow-up training on caring for infants’ oral health.

While the main educational messages delivered to pregnant women mirrored those delivered to Head Start parents, additional topics specific to pregnancy were also addressed. These topics included how to care for teeth during pregnancy, key milestones for care during pregnancy, prevention of the transmission of dental caries, and the use of xylitol products. In addition, contact with pregnant women also focused on encouraging dental visits and working with women to find access to dental providers.

Grantee staff, including home visitors and oral health coordinators, typically provided education to pregnant women. Grantees also partnered with dental hygienists, nursing students, and Women, Infants and Children (WIC) staff to deliver oral health education.

Education for Children

According to record-keeping system data, more than 80 percent of the OHI grantees provided oral health education to children at least monthly from February through May 2007 (Table III.1). To encourage healthy dental hygiene habits among Head Start children, grantees reported educating children on how to care for their teeth, specifically proper tooth brushing techniques. Education also focused on healthy eating and nutrition and what to expect during dental appointments (see box). Education for children most commonly occurred in the classroom or during home visits (75 percent of grantees). However, staff used other opportunities to teach children about the importance of oral health, such as at dental appointments and special events. For example, some grantees held events for Dental Health Month and provided oral health education at community celebrations and health fairs.

Main Topics Covered During Education with Children
N = 52 grantees.
	Percentage of Grantees
How to care for teeth	48
What to expect during dental visits	29
Healthy nutrition	13

Grantees used various materials to support lessons about oral health. Lessons frequently included reading a storybook about caring for teeth or visiting the dentist. Storybooks were often included in curricula materials or purchased to support oral health lessons. Grantees also had puppets available in classrooms and during home visits. Staff used puppets with oversized teeth and toothbrushes to demonstrate tooth brushing techniques and had puppets of dentists available for children to play with and familiarize themselves with dental professionals’ white coats and tools. Other grantees used models of teeth to demonstrate proper dental hygiene. Dramatic play centers helped familiarize children with the tools dentists and dental hygienists use, such as mirrors and flashlights. These materials were included in dramatic play centers with other props, such as white coats, to allow children to become comfortable with the objects they could expect to see at the dentist’s office. One grantee even reported housing a dental chair in classrooms for children to sit in prior to a visit from a dentist.

In nearly three-fourths (73 percent) of grantees, teachers and home visitors carried out oral health education activities with children by integrating oral health lessons into the daily, weekly, or monthly lesson plans. Eleven percent of grantees required teachers to provide oral health lessons either weekly or monthly, and some were required to document oral health objectives in lesson plans. In addition to education provided by teachers and home visitors, grantee staff, mainly oral health specialists and dental hygienists, provided education to children. Often these staff members would visit classrooms or accompany home visitors a couple times a year to teach children about oral health. These visits frequently occurred in conjunction with dental services. For example, hygienists reported visiting classrooms a week or a few days before they were scheduled to conduct screenings and fluoride varnishes. These visits had three main objectives: (1) introduce the hygienists to the children, (2) present a lesson on oral health, and (3) demonstrate the service they would be providing to reduce children’s fears.

Curricula Used for Oral Health Education

To support oral health education, 67 percent of grantees reported using one or more oral health curricula. Rather than relying solely on one curriculum, most grantees reported using selected components of one curriculum in combination with other curricula or resources. Grantees explained that the combination of various curricula allowed them to better tailor their oral health education to the needs of families. For example, drawing on multiple resources enabled grantees to target messages to families that speak multiple home languages, parents with low literacy levels, and families served through multiple program options (for example, home visits and classroom presentations). Moreover, staff drew from multiple curricula to target educational messages to parents, preschool children, and pregnant women.

Commonly Used Curricula by OHI Grantees
N = 52 grantees.
	Percentage of Grantees
“Bright Futures, Bright Smiles”	19
“Cavity Free Kids”	15
“Open Wide”	8
“Bright Futures in Practice”	6
University developed	4
State or county health department developed	13

Grantees reported using widely available curricula as well as locally or regionally designed curricula, such as those developed by state departments of health, local universities, and regional initiatives (see box). The most commonly cited curriculum used by grantees was “Bright Futures, Bright Smiles: An Oral Health and Early Literacy Program for Head Start and Early Childhood Programs” developed by Colgate (Colgate Bright Futures, Bright Smiles 2003). Colgate’s “Bright Futures, Bright Smiles” contains resources for promoting early literacy while helping children ages 3 to 8 establish and maintain positive oral health behaviors. Available materials include a teacher’s manual and classroom posters, as well as storybooks for children and parent booklets. The materials are available in both English and Spanish. Materials are available at low cost, and many materials are available free of charge online. Other commonly used curricula included “Cavity Free Kids” (Huntley, B., and J. Hagen 2004a; Huntley, B., and J. Hagen 2004b), “Open Wide” (Holt, K., and R. Barzel 2004), and “Bright Futures in Practice” (Casmassimo, P. and K. Holt 2004).

Thirteen percent of grantees reported using OHI funds to develop a compilation of resources and materials on oral health. These grantees reported researching evidence-based curricula and resources, determining the curricula and resources most appropriate for the families they serve, and compiling the materials and resources they found most useful for their program. These materials and resources were used to train Head Start staff and parents and to create packets of information for Head Start teachers and family service workers. Two of these grantees described developing resources and materials on oral health as the main focus of the OHI. One developed and piloted a comprehensive curriculum, which includes components for children, pregnant women, and parents, which it will implement in all Head Start centers in the 2007-2008 program year. The other grantee collaborated with community partners to develop and produce videos/DVDs and booklets about oral health for families. The materials were developed in English and Spanish and at a reading level that is accessible to parents.

An important consideration for grantees when selecting or developing curricula was finding materials that were culturally and linguistically appropriate for the populations they served. Grantees often reported selecting specific curricula because the materials were available in Spanish or were at an appropriate reading level for parents. In order to serve all families, grantees translated materials into other languages, such as Arabic, and developed materials at third-grade reading levels. One oral health specialist serving a program with a high percentage of families from Mexico and Colombia accessed resources from the departments of health and dental associations in those countries via the Internet to share with families.

Establishing Dental Homes

Establishing a dental home is an important step in increasing access to care and implementing a schedule of routine preventive care and treatment if needed for children and families. Head Start Program Performance Standards require that Head Start grantees in collaboration with parents and as quickly as possible, but no later than 90 calendar days from the child’s entry into the program, make a determination as to whether or not each child has an ongoing source of continuous, accessible health care. If a child does not have a source of ongoing health care, grantees must assist the parents in accessing a source of care (Administration for Children and Families 2007). The National Head Start Oral Health Resource Center defines a dental home 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” (National Head Start Oral Health Resource Center 2007).

When asked during telephone interviews how they defined a dental home, 62 percent of grantees reported a dental home as an ongoing, regular, or continuous source of care. In addition, staff at 29 percent of grantees included in their definitions that dental homes must provide comprehensive care, including both preventive and treatment services as needed. Staff at another 15 percent of grantees defined a dental home as providing accessible care; that is, families are easily able to make appointments and receive care in cases of emergencies. Mobile clinics or vans, therefore, do not meet this definition. Other important characteristics of dental homes cited by grantees included that care was affordable (6 percent) and culturally appropriate (6 percent) and that dental providers were willing to accept other family members in addition to the Head Start child (4 percent).

Data on establishment of dental homes as reported by grantees through the record-keeping system illustrate the difficulties grantees face finding dental homes for families. Through May 2007, some 50 percent of children and 20 percent of pregnant women had established dental homes (Table III.2).2 These rates are lower than national Head Start averages,3 likely attributable to the high need of these grantees to improve oral health care (Hamm 2006). Of children and pregnant women with a dental home, about half had a dental home established before enrolling in Head Start. Over one-third of dental homes were established within the first three months of program enrollment.

Table III.2. Dental Home Status of Children and Pregnant Women
		Percentage of Children	Percentage of Pregnant Women
Participants with a Dental Home Established		50	20
Number of Months After Enrollment in Head Start Dental Home Established	Had dental home prior to enrollment in Head Start	25	14
	0–3 months	19	6
	4–6 months	3	0
	7–9 months	<1	0
	More than 9 months	2	0

Source: Record-keeping system data from 51 grantees, February 1 to May 31, 2007.
Note: N = 8,687 children and 168 pregnant women enrolled in the OHI. Missing data range from 4 to 126 across items because data entry was incomplete.

Meeting the requirement to establish a dental home in communities with limited dental providers, specifically finding providers willing to serve young children and accept Medicaid, is challenging. In order to meet this challenge, 85 percent of grantees reported helping families establish a dental home for children. Of these, 35 percent described establishing dental homes as a major goal or objective of the OHI. Most of these grantees were already carrying out these activities prior to the OHI but are focusing the grant resources to further support this component. The main strategy grantees described using to help families establish dental homes for children was referring them to local dentists; often these were dentists that the grantees had established partnerships with (see box). Another 12 percent of grantees reported partnering with a specific provider or network of providers that could provide dental homes for all Head Start children.

Strategies to Help Families Establish Dental Homes for Children
N = 52 grantees.
	Percentage of Grantees
Referrals for families	73
Partnering with one provider to serve all children	11

Four percent of grantees described establishing dental homes for all Head Start families as unrealistic given the limited number of dental providers in their communities who accept clients with Medicaid. Migrant/Seasonal Head Start grantees were more likely than other grantees to report on the limited opportunities to establish a dental home because of the high migration rate of families. These grantees explained that because many families are in the area for only a limited amount of time each year, and Medicaid benefits are not portable to other states, even families with dental homes were likely to spend a significant part of the year with limited or no access to dental services.

Preventive and Treatment Oral Health Services

Paramount to the prevention and early detection of early childhood dental caries is the provision of preventive oral health services. Risk assessments and the provision of needed followup and treatment are identified as key components to preventing dental caries (American Academy of Pediatrics 2003). To promote oral health, grantees provided or assisted families in receiving risk assessments, preventive services, and treatment services.

Risk Assessments

Individual risk assessments are especially important for Head Start children, who are often at higher risk for dental disease. Risk-assessment recommendations for Head Start children and pregnant women include identifying previous caries experience, precavity lesions, and visible plaque, as well as perceived risk by examiners (Kanellis 2000). According to the American Academy of Pediatrics “Oral Health Risk Assessment Timing and Establishment of the Dental Home Policy Statement” (2003), every child should begin to receive oral health risk assessments by age 6 months by a qualified pediatrician or pediatric health care professional. Risk assessment tools, such as the Caries Risk Assessment Tool (American Academy of Pediatric Dentistry 2006), are available to assist health care professionals in determining the patient’s relative risk of caries. In the case of the very young patient, a risk assessment to identify parents (usually mothers) and infants with a high predisposition to caries can easily be performed by taking a simple dental history from a new mother. Questions directed at dietary practices, fluoride exposure, oral hygiene, utilization of dental services, and the number and location of the mother’s dental fillings can give a relative indication of the mother’s baseline decay potential. Frequent sugar intake, low fluoride exposure, poor oral hygiene practices, infrequent utilization of dental services, active decay, and multiple dental fillings in multiple quadrants of the mouth indicate a high caries risk in the mother (American Academy of Pediatrics 2003).

More than half of the OHI grantees (63 percent) reported conducting risk assessments for Head Start children and pregnant women. Another 31 percent reported referring children and pregnant women to dental homes or other dental providers for risk assessments; however one-quarter of these did provide risk assessments if children and pregnant women did not have dental homes. Ten percent of grantees did not provide or refer children for formal risk assessments. These grantees explained that assessments were not necessary because all of the children they serve are considered high risk. One grantee explained that an oral health task force at the program was in the process of researching the best approach to providing risk assessments.

The results of risk assessments typically categorize children and pregnant women into specific risk categories, such as high risk, moderate risk, and low risk. Once a risk category was applied, grantees reported using this information to triage children and pregnant women for services. Children and pregnant women categorized as high risk were referred for immediate attention by a dental professional; those at moderate risk were referred to a dental professional, although services were considered less urgent; and those identified as low risk were instructed to continue routine preventive dental treatments. Head Start grantees also used risk assessment results to tailor education and treatment plans for individual families and to track progress of care.

Preventive and Treatment Services

To meet the oral health needs of children and pregnant women, grantees implemented a range of strategies to obtain preventive services and needed follow-up treatments. Grantees’ strategies included direct provision of services, referrals for services, and a combination of the two. During telephone interviews, most grantees (77 percent) reported providing some preventive services; nearly all grantees (92 percent) referred children and pregnant women to dental professionals for treatment services.

Grantees commonly planned to provide or arrange dental screenings and fluoride treatments (including varnish applications, rinses, and prescription tablets). Fewer grantees provided cleanings and dental examinations; instead, families were typically referred to dental homes or another dental provider for these services. Eight percent of grantees reported providing some treatment services, such as fillings. Grantees that provided some treatment services either operated or partnered with an organization that operated a mobile van, provided on-site dental clinics, or designated clinic days when appointments were made for Head Start children. All grantees referred families to dental providers for more extensive restorative treatments.

According to program record-keeping system data, 34 percent of children received at least one service between February and May 2007; 25 percent received more than one service (Table III.3). For pregnant women, the rates were lower with 17 percent receiving one service and 13 percent receiving more than one service. The most common types of services children received were fluoride varnishes (22 percent), followed by dental screenings (11 percent) and dental exams (15 percent). Ten percent of pregnant women received dental screenings; 7 percent received dental exams and cleanings.4 Far fewer children and pregnant women received treatment services, but of those who did, most received fillings.

Table III.3. Treatment and Preventive Services Provided to Children and Pregnant Women
		Percentage of Children	Percentage of Pregnant Women
Received at Least One Service		34	17
Received More Than One Service		25	13
Preventive Services	Dental screening	11	7
	Dental exam	15	10
	Cleaning	10	7
	Fluoride rinse	1	0
	Fluoride varnish	22	4
	Fluoride tablets prescribed	<1	0
	Xylitol wipes	2	0
	Preventive root planing and scaling (preventive)	0	1
	Topical fluoride	5	1
	Dental sealants	<1	0
	Other fluoride	<1	1
Treatment Services	Fillings (1–2)	2	4
	Fillings (3 or more)	2	1
	Extractions (1–2)	1	1
	Extractions (3 or more)	<1	0
	Steel crowns	<1	1
	Root canal	<1	1
	Bridge/dental implant	<1	0
	Therapeutic root planing and scaling (therapeutic)	<1	0
	Treatment requiring hospitalization and/or sedation	<1	0
	Other	2	1

Source: Record-keeping system data from 51 grantees, February 1 to May 31, 2007.
Note: N = 8,687 children and 168 pregnant women enrolled in the OHI. Missing data range from 6 to 59 across items because data entry was incomplete.

Table III.4. Characteristics of Preventive and Treatment Services
		Percentage of Records with Preventive Services Onlya	Percentage of Records with Treatment Services Onlyb	Percentage of Records with Both Preventive and Treatment Servicesc	Percentage of Total Services
Referred for Service by Grantee		52	5	5	63
Provider of Service	Grantee: health specialist	4	0	0	4
	Grantee: dental hygienist	25	0	0	26
	Grantee: other	3	0	0	3
	Community partner	44	6	7	56
	Other community provider	7	2	2	10
Location of Service	Grantee site	57	2	0	59
	Service provider office	21	6	6	33
	Hospital	0	0	0	1
	Home	2	0	0	3
	Mobile van or clinic	2	0	1	3
	Other	0	0	0	1
Support Services Provided		29	5	4	38
Type of Support Services Provided	Help making appointment	45	10	7	61
	Transportation	15	4	3	23
	Translation	11	1	2	15
	Other	44	5	5	54
Provider of Support Services	Grantee: health specialist	38	8	5	51
	Grantee: dental hygienist	3	1	0	4
	Grantee: other	28	4	6	38
	Community partner	3	0	1	4
	Other community provider	2	0	0	3
Follow-Up Service Required		18	4	3	26
If Followup Required, Status of Followup	Referral made	21	3	1	25
	Appointment pending	41	12	10	63
	Followup complete	12	3	2	18
If Followup Complete, Number of Months Between Service Date and Date Followup Completed	0–2 months	63	19	14	96
	3–4 months	4	0	0	4

Source: Record-keeping system data from 51 grantees, February 1 to May 31, 2007.
Note: N = 3,842 service records. Missing range from 0 to 183 across items because data entry was incomplete.
a Preventive services include dental screenings, clinical exams, cleaning, fluoride rinse, fluoride varnish treatment, fluoride tablets prescribed, xylitol wipes, and root planning and scaling (preventive).
b Treatment services include fillings, extractions, steel crowns, root canal, bridge/dental implant, root planing and scaling (therapeutic), and treatment requiring hospitalization and/or sedation.
c Because the record-keeping system allows users to select more than one type of service per record, some records included both preventive and treatment services.

The delivery of services was conducted by a variety of providers, most often by a community partner (56 percent of services; Table III.4). Dental hygienists on staff or under contract to grantees provided one-quarter of preventive services. Typically, these hygienists were under the supervision of a dentist; many of these dentists were also community partners or within the network of dentists serving Head Start children.5 Other grantees contracted with private dental hygienists, partnered with dental hygienist students, or worked with dental hygienists who volunteered their time.

The primary location at which children and pregnant women received services varied by type of service, but nearly all services were provided either at the grantee site or at a provider office (Table III.4). Most preventive services were conducted at the grantee site; in contrast, treatment services more commonly were delivered at provider offices. Models for providing services on site included having dental hygienists or dentists conduct services in classrooms or arranging for dental providers to offer on-site clinic days when families could make appointments for children. A few grantees reported partnering with organizations that operate mobile dental vans. The vans would visit various Head Start centers or other community locations to offer services to children. To support these on-site services, grantees used OHI funds to purchase portable dental equipment and other supplies.

Follow-up treatment was required for about one-quarter of the services and was completed on close to 20 percent of these services (Table III.4). For the majority of follow-up services, appointments were pending. This status likely reflects the short data collection window (February through May 2007), compounded by long waiting lists for appointments at many dental offices and clinics.

According to record-keeping system data, grantees referred children and pregnant women to about two-thirds of services (Table III.4). During telephone interviews, nearly all grantees (94 percent) reported having a system in place for referring families to dental providers. Grantees usually maintained lists of providers who were willing to serve Head Start families. As needed, programs would share the list with families. One grantee included the names and contact information of providers willing to serve Head Start families in a community resource guide that was given to families at enrollment. Another grantee operated a referral hotline that families could call when they needed referrals for all health care, including dental care. All grantees reported having a system for referring families to dental providers in place prior to the OHI; however, a few grantees aimed to improve this system through the OHI, and nearly all grantees planned to expand the network of dental providers willing to accept referrals through the OHI. One grantee worked with a community partner to refer clients to services. The community partner operated a referral network, and outreach workers communicated directly with Head Start families to help them locate providers. When making referrals, grantees stressed the importance of finding providers who could work with families’ characteristics and needs. These factors included ensuring that providers accepted families’ insurance coverage; were in convenient locations; and, when possible, provided culturally competent services, such as having staff or interpreters available for families that spoke a language other than English.

To cover the costs of services, staff described four main approaches in telephone interviews: (1) billing Medicaid or another insurance provider, (2) receiving in-kind donations of dental professional time, (3) using OHI funds for materials/supplies/equipment, and (4) using OHI/Head Start funds for services. The cost of treatment services was almost always covered by health insurance, including Medicaid, SCHIP, and Indian Health Services, or paid for using regular Head Start funds. Some grantees reported using OHI funds as additional funding or back-up funding. Few grantees reported using OHI funds as a primary source of funding for oral health services.

Support Services

Types of Support Services Available to Families
N = 52 grantees.
	Percentage of Grantees
Transportation	77
Making appointments	75
Translation	54
Reminder notices	21
Accompanying to Appointments	10

To facilitate the provision of preventive and treatment services, grantees reported providing a range of support services. Of the dental services recorded in the record-keeping system, support services were provided to families for more than one-third of oral health preventive and/or treatment services (Table III.4). Grantee health specialists were typically responsible for providing or arranging these services (51 percent). Other grantee staff, such as family service workers and home visitors, also assisted with providing support services to families.

In telephone interviews grantees reported that the types of support services available to families included providing transportation or transportation assistance, helping families make appointments, providing or arranging for interpreters, sending out reminder notices or making reminder calls to families about appointments, and accompanying families to appointments (see box). On a more limited basis, grantees reported reimbursing families for the cost of child care during appointments and providing funding to cover the costs of travel and lodging for overnight stays. Grantees also reported helping families access services available through providers and others, such as shuttle services for Medicaid clients and interpreters available through providers.

Distribution of Supplies

Oral hygiene supplies were distributed to families to reinforce educational messages and to ensure that families had the tools they needed to engage in healthy dental hygiene. According to record-keeping system data, 78 percent of grantees distributed supplies to Head Start children between February and May 2007 (Table III.5). In telephone interviews with grantee staff, 92 percent of grantees reported distributing supplies at some point during the program year. The primary recipients of oral hygiene supplies were children. In addition, more than half of the grantees also distributed supplies to parents and siblings. Supplies were commonly distributed at parent meetings and training events when oral health topics were discussed during home visits, and were sent home with children. Grantees also distributed supplies at community events.

The types of supplies distributed to families included toothbrushes, toothpaste, dental floss, timers, toothbrush covers, disclosing tablets that expose plaque on teeth, xylitol products, gauze and finger cloths for wiping infants’ gums, and dental mirrors for parents to use to check children’s teeth (Table III.5).

Table III.5. Oral Hygiene Supplies Distributed to Families
		Percentage of Grantees
Distributed Oral Hygiene Supplies to Families at Least One Month		78
Types of Oral Hygiene Supplies Distributed to Families at Least One Month	Toothbrushes	74
	Fluoride toothpaste	73
	Floss	59
	Xylitol wipes	29
	Xylitol gum	23
	Fluoride rinse	6
	Other supplies	55

Source: Record-keeping system data from 51 grantees, February 1 to May 31, 2007.
Note: N = 51 grantees.

1 ”Lift the Lip” is a tool kit consisting of a descriptive video and flip chart developed by the University of Washington School of Dentistry to instruct families and program staff on how to conduct a brief oral health screening of infants’ and toddlers’ teeth (Lee et al. 1993). (back)

2 Regional differences existed in the rates of children and pregnant women with dental homes established, with more than half of children reported as having dental homes in regions III, VIII, IX, and X, compared to less than half in other regions. Across all regions, grantees reported higher percentages of dental homes established for children than for pregnant women. This disparity may reflect the difficulties that adults on Medicaid and other public insurance have finding dental care. (back)

3 In 2005, some 47 percent of children entered Head Start without an ongoing source of dental care; by the end of the program year, 82 percent of children had a dental home (Hamm 2006). (back)

4 These findings are likely due to the timing of the data collection period (February through May) and the fact that grantees often provided fluoride varnishes two to three times per year. Dental exams and screenings were more commonly provided at the beginning of the program year. (back)

5 Dental hygienists are required by law, in most states, to be under the supervision of a dentist. Many states allow hygienists to go into schools, nursing homes, and other public health facilities to provide preventive services to underserved populations (Gehshan et al. 2001). (back)

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Last Updated: February 6, 2008