Dental hygienists' role in establishing dental homes for head start children.

Overview of Head Start

Over the past 50 years, major improvements in oral health have been seen nationally. Progress has been made in reducing the extent and severity of common and often preventable oral diseases. However, for many Americans, especially children from minority racial and ethnic groups and children from socio-economically disadvantaged families, dental caries is common and widespread, and it remains the single most common chronic disease of childhood. (1)

During the years of 1999 and 2000, 23 percent of two- to four-year-olds experienced dental caries in their primary dentition. (2) America's youngest and poorest children, aged two to four years and living below the poverty level, have nearly three times the dental caries as children of families at higher income levels. (2-3) This population of young children is eligible to participate in a federally funded program called Head Start. Head Start is administered through grants to over 1600 community-based organizations and offers comprehensive child development services including health. Head Start program specialists, director's staff and parents report that access to oral health care is the number one health issue affecting Head Start Programs. (4)

The Head Start Program, established in 1965, promotes school readiness by enhancing the social and cognitive development of children through the provision of services including education, health, nutrition and social services. (5) Early Head Start, established in 1995, provides services to pregnant women and children from birth to age three. Participants are eligible if they meet federal poverty guidelines ($20,650 for a family of four in 2007). (6)

Head Start, which currently serves approximately 1 million children, has a long tradition of delivering comprehensive services designed to foster healthy development in the most vulnerable young children. (5-6) Head Start and Early Head Start follow federal regulations including a set of performance standards for providing comprehensive health care. The standards that relate to dental care require that the Head Start grantees report on the establishment of dental homes as well as reporting the number of children receiving dental exams, preventive procedures and treatment. Every child enrolled in Head Start is required to have a dental examination within 90 days of enrollment. (7) This population has numerous challenges and barriers to receiving these dental examinations and needed dental care. While the majority of Head Start families are enrolled in Medicaid, many dentists do not accept Medicaid patients. There is a shortage of dentists who are willing to see young children, and often there isn't even one dentist located in the geographic region near the Head Start Center. There is also the barrier of a lack of oral health education for Head Start parents, staff and children. The preventive procedures necessary to reduce oral disease in this population are often not available or even known. (8)

The dental hygienist graduating from an accredited program has received experience in working with underserved populations such as those in Head Start and has studied the issues that present barriers to education, disease prevention and access to care. The dental hygienist is competent in many domains, including core competencies, health promotion, community involvement, patient care and professional development. (9) The competencies involving assessment, screenings and referrals for various population groups fall under the domain of community involvement (Table I).

The dental hygienist is a qualified health professional competent to assess the oral health needs of Head Start children, as well as the quality and availability of oral health resources and services to answer them. In the dental hygienist's role in the community, the health and safety of the patient comes first in assessing, planning and implementing programs that will provide comprehensive oral health care or a dental home for every patient.

Head Start and the Maternal and Child Health Bureau Partnership

In 2001, an intra-agency agreement (IAA) was initiated between the Administration for Children and Families (ACF) Office of Head Start and the Health Resources Services Administration's Maternal and Child Health Bureau (HRSA MCHB) to establish partnerships that would improve the oral health of Head Start children nationally. The partnerships developed within this IAA supported seven projects including Head Start Oral Health Forums (Table II).

Regional Head Start Oral Health Forums were held in each of the 10 Head Start Regions as well as two forums for Native American and migrant children in Head Start. (For a map of ACF Head Start regions, visit ACF HS Regions at www.acf.hhs.gov/programs/oro/regions/ acf_regions.html). The purpose of the regional forums was to address prevention, oral health education and access-to-care issues and identify strategies and key roles of regional agencies in the plan to improve the oral health of Head Start and Early Head Start children. (10) Through the IAA, the Association of State and Territorial Dental Directors (ASTDD) provided funding at the state level to support the state Head Start Oral Health Forums and follow-up activities. The participants at these forums included Head Start administrators, staff and parents as well as oral health professionals including dentists and dental hygienists from academia, private practice and state oral health programs. The purpose of the state forums was to solicit input from a multidisciplinary, multi-organizational group of stakeholders to develop state action plans to improve Head Start oral health. Components of the action plans included enhancing prevention and oral health education, as well as increasing access to oral health services for Head Start and Early Head Start. Dental hygienists were represented at every Regional and State Head Start Oral Health Forum and have been active in the implementation of the statewide action plans. (10)

Professional forums were held between Head Start and the following organizations: American Dental Association (ADA), American Dental Educators Association (ADEA), American Academy of Pediatric Dentistry (AAPD), the Hispanic Dental Association (HDA) and the American Dental Hygienists' Association (ADHA). The purpose of the professional forums was to involve some key national organizations to gain their support for initiatives to improve the oral health of Head Start. The summary of the ADHA forum reports on the challenges of providing oral health services to Head Start but more importantly describes strategies for overcoming these challenges on a national level. Table III lists potential opportunities for collaboration between ADHA, MCHB and Head Start as described in the ADHA forum summary. The final reports from these professional forums and the regional and state forums can be found on the National Maternal and Child Oral Health Resource Center's Web site at www.mchoralhealth.org/HeadStart/hsforums.html. (10)

As a result of the regional, state and professional forums, several state dentalhygienists' associations have initiated Head Start projects following the ADHA Head Start recommendations for collaboration. For example, the Texas Dental Hygienist's Association has partnered with Head Start in a joint effort titled "Healthy Start for Texas Teeth," in which hygienists are adopting Head Start centers and addressing the prevention, education and access-to-care needs within Head Start centers. Fluoride varnish programs are the initial focus of the preventive services; education for Head Start parents and staff is being provided and screenings with referral and follow-up to pediatric dentists, general dentists and community health centers are being provided. The project goal is to have a dental hygienist or dentist on all the Head Start health services advisory boards working with the Head Start centers to find a dental home for every child. (11)

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Connecting Head Start Children with Dental Homes

The concept of the dental home evolved from the American Academy of Pediatrics' (AAP) concept of medical home. AAP states, "Pediatric primary health care is best delivered where comprehensive, continuously accessible and affordable care is available and delivered or supervised by qualified child health specialists." (12) The dental home therefore is similar in that it provides comprehensive oral health care starting with an oral health examination by a dentist for infants and young children (6 months after the first tooth erupts or by 12 months of age) and provides preventive services that meet each child's needs. The components of the dental home as described by the AAPD are listed in Table IV. (13)

As licensed professionals, dental hygienists are a valuable resource in the process of establishing dental homes for Head Start children. Their services include screenings, prevention and education, referral for treatment and assistance in the coordination of follow-up care. They are facilitators for finding and establishing dental homes that will allow the Head Start child an opportunity to receive comprehensive oral health care. Dental hygienists working with Head Start are enabling the Head Start grantee to meet the oral-health-related performance standards and to bring improved oral health to every Head Start child.

Examples of programs where dental hygienists are involved with finding dental homes for Head Start children are nationwide. Many states have adopted less restrictive practice acts to allow dental hygienists to work in public health settings including Head Start. Promoting expanded practice settings and removing restrictive supervision barriers are essential to the success of improving the oral health of underserved populations. (14) The National Maternal and Child Oral Health Resource Centers' Web site at www.mchoralhealth.org/HeadStart/presentations, html, provides descriptions of successful partnerships between oral health and Head Start. (15) These programs focus on education, disease prevention and service delivery to improve the oral health of pregnant women, infants and children enrolled in Head Start. At this Web site programs are described including the partners, which include dental hygienists, the program activities and contact information. One example, the Minnesota Program, is a partnership that began in 2006 as a collaborative practice approach to meet the dental performance standards for Minnesota Head Start Programs. The partners include Minnesota Head Start; the state's dental association and dental hygiene association; and Apple Tree Dental a non-profit organization with the mission to improve the oral health of people with special dental access needs and whose patients include low-income children and families. In the five years preceding the establishment of this project, only about 70 percent of children enrolled in Minnesota Head Start had received the required oral examination. The program employed the community collaborative practice approach to increase the percentage of enrolled children who receive early and appropriate oral health care. (15)

In the Minnesota program description, collaborative practice dental hygienists provide education, preventive services (including fluoride varnish) and a standardized assessment and triage on-site in Head Start centers. ASTDD's Basic Screening Survey (BSS) is used as the screening tool. (16) Benefits of this approach include disease prevention and education provided to the children in a familiar, supportive environment. In addition, the collaborative approach provides the opportunity to strengthen working relationships among dental hygienists and dentists in the state. The standardized assessment, triage and referral mechanism allows dental hygienists to work effectively with community clinics, nonprofit organizations and private dentists to link Head Start children with dental homes and ensure the oral health of children enrolled in Minnesota Head Start. (15,16)

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Call to Action

Becoming involved with Head Start is a rewarding experience and contributes to the improvement of oral health for all children. Dental hygienists interested in working with Head Start should contact their state dental hygienists' association and their component dental hygiene organization to determine the level of services presently being offered and how best to organize efforts and get involved. Review of the State Head Start Oral Health Action plans online at www.astdd.org will provide valuable background information. (17) Dental hygienists can also locate a Head Start center directly by visiting the Web site www.adha.org/public health/index.html and following the link titled "Find a Head Start Center near you." Dental hygienists can contact Head Start centers and offer assistance with parent and staff education as well as participation on the health services advisory board. The common goal of the dental profession and Head Start is to see that the children obtain the dental care essential to their health and school readiness. There will be various paths and collaborative opportunities for accomplishing this task.

The National Maternal and Child Oral health Resource Center's Head Start activities are supported by the intra-agency agreement between the Office of Head Start and the Maternal and Child Health Bureau with the goal of enhancing the quality of oral health services for pregnant women, infants, and children enrolled in Head Start. (18) The Resource center has developed a wealth of information, such as tip sheets for Head Start parents and staff, fact sheets including "What Dental Hygienists Need to Know About Head Start", and a free online newsletter titled "Oral Health Alert:Focus on Head Start" that can assist dental hygienists in getting involved in Head Start. The Resource Center's Web site (www.mchoralhealth.org/Head Start) is an excellent starting point for dental hygienists interested in learning more about Head Start and willing to join dental hygienists involved in finding dental homes for children enrolled in Head Start programs. Making a difference in the quality of life for these children is certainly a fulfilling role and one that the dental hygienist is well qualified to take on.

References

(1.) U.S. Department of Health and Human Services (DHHS). Oral health in America: a report of the Surgeon General. Rockville, Md.: U.S. Department of Health and Human Services, 2000.

(2.) National Centers for Health Statistics, Centers for Disease Control and Prevention: Healthy People 2010 progress review: briefing book materials -data summary table for focus area 21 -oral health, March 17, 2004.

(3.) Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc 1998; 129:1229-38,.

(4.) Brocato R. Head Start and partners forum on oral health. Head Start Bulletin 2001; 71:1-43. Washington, D.C.: Head Start.

(5.) Office of Head Start. About Head Start. 2007. Available at www.acf.hhs.gov/programs/hsb//about/index.htm.

(6.) Department of Health and Human Services. The 2007 HHS poverty guidelines. 2007. Available at: http://aspe.hhs.gov/poverty/07/ poverty.shtml.

(7.) Code of federal regulations 45, part 1304 -program performance standards for the operation of Head Start programs by grantee and delegate agencies, subpart B -early childhood development and health services and C-family and community partnerships, pp. 121-133. October 1, 2005.

(8.) American Dental Hygienists' Association (ADHA) and HRSA/MCHB forum on enhancing partnerships for Head Start and oral health. Chicago, Ill., forum summary. Oct. 9, 2003. Available at www.mchoralhealth.org/Head Start/hsforums.html Accessed Dec. 19, 2007.

(9.) American Dental Association (ADEA): Competencies for entry into the profession of dental hygiene: ADEA section on dental hygiene (approved March 2003 House of Delegates).

(10.) Regional, State and Professional Head Start Oral Health Forum reports. Available at www.mchoralhealth//hsforums.html. Accessed Dec. 19, 2007.

(11.) Texas Dental Hygienists' Association. Healthy Start for Texas Teeth. Available at www.texasdha.org/about_us/index.htm.

(12.) Hale KJ, et al. American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment, timing and establishment of the dental home. Pediatrics 2003; 111:1113-1116,.

(13.) American Academy of Pediatric Dentistry. Policy on the dental home. Available at www.aapd.org/media/Policies_Guidelines/P_DentaIHome.pdf. Accessed Dec. 19, 2007.

(14.) American Dental Hygienists' Association (ADHA). Focus on advancing the profession. ADHA, Chicago, Ill. June 2005. Available at www.adha. org/downloads/ADHA_Focus_Report.pdf. Accessed Dec. 19, 2007.

(15.) Office of Head Start Webinars. Partnerships to improve oral health in Head Start. 2007. Available at www.mchoralhealth.org/HeadStart/ presentations.html. Accessed Dec. 19, 2007.

(16.) Association of State and Territorial Dental Directors Basic Screening Survey (BSS). Available at www.astdd.org/docs/bss_manual_9-25-03.pdf.

(17.) State Head Start Forum Action Plans. Association of State and Territorial Dental Directors Web site. Available at www.astdd.org/index.php?template=head start.htm Accessed Dec. 19, 2007.

(18.) National Maternal and Child Oral Health Resource Center:Focus on Head Start Web site: Available at www.mchoralhealth.org/HeadStart.

Kathy Voigt-Geurink, RDH, BS, MA, is an associate professor in the Department of Dental Hygiene, School of Allied Health Sciences, University of Texas Health Science Center. Her responsibilities include teaching community oral health and supervising student service-learning projects. Prior to her teaching, Geurink worked as a public health dental hygienist in Minnesota, Wisconsin and Colorado initiating statewide community oral health programs for underserved populations. She has worked with Head Start Programs throughout her career to improve the oral health of children and families. She presently serves as the Head Start Oral Health Project Coordinator for the Association for State and Territorial Dental Directors (ASTDD) and she is the Region VI Head Start Oral Health Consultant. Her publications include the textbook Community Oral Health Practice for the Dental Hygienist, Elsevier 2005.

Table I. Dental Hygiene
Competencies' Community
Involvement (9)

CM.1 Assess the oral health needs of the
community and the quality and availability
of resources and services

CM.2 Provide screening, referral, and
educational services that allow clients to
access the resources for the health care
system

CM.3 Provide community oral health services in
a variety of settings

CM.4 Facilitate client access to oral health
services by influencing individuals and
organizations for the provision of oral
health care

CM.5 Evaluate reimbursement mechanisms and
their impact on the patient or client's
access to oral health care

CM.6 Evaluate the outcomes of community-based
programs and plan for future
activities

Adopted by the ADEA House of Delegates, 2003

Table II. Projects Supported by
the Intra-Agency Agreement
(IAA)

1. Regional Head Start Forums *

2. State Head Start Forums *

3. Professional Head Start Forums *

4. National Head Start Oral Health Resource
Center *

5. Regional Head Start Oral Health Consultants
(5 are dental hygienists)

6. National Oral Health Policy Center

7. Pediatric Dentistry Training Projects

* Projects discussed in this article

Table III. Opportunities for
Collaboration between ADHA,
MCHB and Head Start

* Encourage access to dental care by increasing
scope of practice and reimbursement
for dental hygienists

* Encourage Head Start Programs to gather
data using the ASTDD BSS Basic Screening
Survey

* Establish communication channels between
ADHA, State Head Start Collaboration
Offices and State Oral Health Programs

* Inventory ADHA dental hygiene components
and programs about Head Start collaborations

* Create a theme for Dental hygiene Month
that targets Head Start

* Have information available on the ADHA
website about Head Start with links to the
Office of Head Start and MCHB information

* Develop a power point presentation online
to be used by dental hygienists in presentations
to Head Start

* Develop model local Head Start events with
community partners

* Establish liaisons with community
leaders/public officials and educate them on
oral health and Head Start

* Support oral health education for Head
Start care providers on weekends and for
CE Credit

* Develop and disseminate oral health curriculum
for Head Start

* Designate an ADHA liaison in each state to
facilitate collaboration between dental
hygiene and Head Start

Available online at www.adha.org/HeadStart

Table IV. Components of a
Dental Home

* An accurate risk assessment

* An individualized preventive program based
on risk

* Anticipatory guidance about growth and
development issues

* A plan for emergency dental trauma

* Information about proper care of teeth and
gums

* Information on proper nutrition and diet

* Comprehensive dental care in accordance
with accepted guidelines and periodicity
schedules for pediatric oral health

* Referrals to dental specialties when needed
services are beyond what is directly provided
in the dental home

AAPD: Policy on Dental Home: www.aapd.org/media/
policies_Guidelines/P_Dental Home.pdf