Toothbrushing and Head Start: What's It All About?

By Dr. Harry W. Bickel, Jr.

Since three- and four-year-old children have trouble tying their shoes, how can we expect them to brush their teeth in the classroom?

Actually I have asked myself this question many times. As a dentist, I think all people should brush their teeth as often as possible. I realize this is impossible in the fast-paced, modern world. As a person who has spent a lot of time in Head Start classrooms, I cannot ignore the fact that classroom toothbrushing is a difficult and time-consuming activity. It is also a messy one.

Consequently, the question arises, "Is it worth it?" I guess that is a matter of personal opinion. If you value teeth, health, and personal hygiene, then your answer will be "yes". In my opinion classroom toothbrushing is worth it, but then again, I am a dentist. Some of my reasons may be different from yours.

For at least a century, dentists have been telling their patients that if they brush their teeth, they will not have tooth decay. Parents and teachers, of course, have been imparting these same pearls of wisdom to their children. The problem is, people still get decay, even if they brush all of the time. Why is this?

The reality is that decay is the result of several factors, toothbrushing or oral hygiene being only one of them. Other major factors are exposure to fluoride, diet (particularly sugar intake), and tooth morphology or structure. If you do not have control of these factors, then the best toothbrushing in the world may not prevent decay. It can, however, help.

Looking at the larger picture illustrates that reducing tooth decay is only one of the possible benefits of good oral hygiene. Without question, there is also a direct relationship between good oral hygiene and healthy gums. Though most people do not realize it, teeth are lost because of gum disease as much as they are lost because of tooth decay. Since gum disease does not affect children, we do not usually think about it in Head Start. However, the people who lose their teeth to gum disease are usually the ones who didn't learn to take care of them as children.

Now, we are finally down to the heart of the matter: It is most important to realize that we can do things for children that will affect them for the rest of their lives. This is what Head Start is all about. This is what we are trying to do by teaching them to brush their teeth. Like so many of the things we do in Head Start, this is simply part of the process of giving children the tools they will need in the future to be happy, healthy, and productive adults.

One goal of classroom tooth brushing in Head Start is to create a desire in the children to have a clean and healthy mouth. We do this by making toothbrushing a part of our daily routine. In other words, we are trying to develop a positive health habit. This is no different than teaching children to wash their hands or flush the toilet or a number of other things that we teach in Head Start. It is simply a different behavior and a different result.

My advice to teachers, then, is to focus on the experience and not the technique. Technique will come later as motor skills improve. For now, make it a positive experience for the children. Make them understand that this is also something they should do at home and continue doing after they leave Head Start.

Now for some questions–

What about the mess?
Do not worry about it. It is certainly not as messy as finger-painting.

Will toothbrushing spread disease?
Not if it is done properly. There should be no more potential for spreading disease from toothbrushing than from many other things we do in Head Start, such as handling dishes or helping children use the bathroom or blow their noses. The key here is to use your head and realize that the bristles of the brushes contain microorganisms, some of which are capable of causing disease. When you place the toothpaste on the brush, make sure that the mouth of the tube does not drag across the brush. Better yet, put the toothpaste on a small square of wax paper and then on the brush.

What kind of toothpaste should I use?
This really does not matter too much. I would suggest using a toothpaste that is approved by the American Dental Association (ADA) since these have been tested and approved. If it does not have the ADA seal of approval, then you really don't know its quality.
Should I use a fluoride toothpaste?
Yes. Recent research has demonstrated that the topical effect of fluoride (directly on the surface of the teeth) may be as great as the systemic effect (via the bloodstream, as in community water fluoridation). Many also recommend that the child not rinse after brushing so that the fluoride will remain on the teeth longer.

What kind of toothbrushes should I use?
Use a children's toothbrush (one with a small head) that has soft bristles. If you do not already have a ready source of toothbrushes, check with one of your local program dentists. He or she should have a number of dental supply catalogs from which you can order. If you really want to get fancy, you can have your program's name printed on the handles.

What toothbrushing method should I use?
I would recommend that you have the children use what is often referred to as the "scrub brush method". This simply means that you place the brush against the teeth and move it in a circular motion. Make sure that the brush goes up near the gum line where much of the plaque is located. Also, do not forget to brush the tops and the insides (tongue side) of the teeth and not just the front surfaces.

Should I use floss?
Though some people may disagree, I think three- and four-year-old children should not attempt flossing, at least not in a group setting. They simply do not have the manual dexterity to do it.

How should I store the toothbrushes?
This is probably the most frequently asked question about toothbrushing. Toothbrushes should be stored in the most hygienic way possible. There are many good ways to do so and people need to decide what works best for their particular situation. I do, however, think that any toothbrush storage should meet certain criteria. Here are the ones that I would suggest:

1. Toothbrushes should be stored in a manner that prevents cross-contamination. This is the basic principle that determines whether or not our storage method is adequate. We do not want to transmit one child's germs to another via the toothbrush. Consequently, toothbrushes must not be allowed to touch one another and must be returned to a proper storage site each time they are used. Finally, toothbrushes must be clearly labeled with the child's name so that each brush returns to the same mouth each time.

2. Toothbrushes should be stored in a manner that allows them to dry properly. It is important, from a microbiological standpoint, that toothbrushes not be allowed to remain moist during storage. The optimum conditions for bacterial growth are dark, warm and moist. Most, but not all, bacteria do not survive well without a source of moisture. This means that wrapping toothbrushes in plastic wrap, or placing them in a container that has no ventilation, is not advisable.

3. Toothbrushes should be kept in individual containers or in a cabinet that can be closed. Many of our Head Start classrooms are in old buildings, where insect control is either impossible or less than optimal. We do not want to hear from Head Start staff who go into their classrooms after hours and find bugs crawling over the toothbrushes!

4. Where possible, toothbrushes should be stored with the bristle end up. This keeps the bacteria that are on the handle from running back onto the bristles during storage. Several different hands may have touched the handle of the brush while it was being used and the brush was probably wet when returned to the holder.

5. Storage containers should be either washed in a dishwasher or sterilized periodically. Over time, as individual containers are used on a daily basis, they tend to build up a lot of material from the toothbrush. While most of this is dried toothpaste, some of it may not be.

One of the things I enjoy most when I walk into a Head Start classroom is for the children to run up to me and tell me that they brush their teeth. They are proud of it. They want to tell me that they are doing it. This, in itself, should illustrate why a commitment to brushing teeth is important

Harry W. Bickel, Jr. D.M.D. is a Health Specialist, Region IV Quality Improvement Center, Western Kentucky University, T: 270-745-4041; E: hbickel@home.com.