La felicidad comienza con una sonrisa saludable

Happiness Begins with a Healthy Smile

Nydia Ntouda: On today's webinar we have Dr. Francisco Ramos Gomez and Maria Del Rocio Galarza, who goes by Rocio. They will be introducing themselves today. You can take it away.

Dr. Francisco Ramos Gomez: Good morning, Rocio, you want to start.

Maria Del Rocio Galarza: Yes of course. My name is Maria Del Rocio Galarza, and I worked for Sesame Workshop for the US Social Impact Department, creating resources for young kids, for families, for providers such as yourselves, and really helping provide a fun, engaging way of talking about different important topics. We are here today for oral health and we're very excited to share some of the resources with you.

Dr. Ramos Gomez: Thank you much, I'm Dr. Francisco Ramos Gomez, I'm a pediatric and public health dentist. I'm a professor and chair at the University of California, Los Angeles. I'm thrilled and happy and grateful to be with you this morning, afternoon for everyone that is on this wonderful webinar through the magic of Head Start and Sesame Street together, what a perfect and amazing combination. We’re going to show you a set of series and some specific objectives, and some videos that they're launching, maybe, Rocio, if you want to comment about the videos, a little bit on the launch of oral health and Sesame Street, which are happy and delighted we have that amazing collaboration.

Maria: Absolutely, this collaboration has been going on for a long time now with UCLA. We have been able to create these wonderful videos that are really very much aligned with some of the messaging that you're going to see today to share with families. The reason why we've created these videos is to help introduce some of the messages, sometimes they can be a great recap for these messages.

One of the best ways is to use them as reminders because we all know that families need reminders to continue to practice these healthy habits. You will find today that we are sharing with you six different videos, all within the topics of this talk, from fruits and vegetables, and the importance of water as are to drink instead of other drinks. Brushy brush, a song that is incredibly catchy, you will see, you will hear it.

Then two other videos; one that really helps us establish a routine for bedtime that includes toothbrushing, and the other one that promotes going to the dentist, particularly at 6 months. All of this is going to time permitting, we're going to be sharing with you. But remember that the best way to use some of these videos really is, yes, it is an introduction most certainly as a reminder. I encourage you to share them in any way you want in [Inaudible] with your families.

Dr. Ramos Gomez: That's exciting is going to be a fun, fun, fun session for all of you. It's exciting and thrilled. For this, we introduce ourselves, our presenters, the objectives of the chat this morning, afternoon with you is to really for specific objectives to explain the importance of meeting foods and drinks with added sugars or really limiting sugary foods and drinks is essential, that's point number one.

Number two, to really explain the need of really engaging parents for tap water drinking. It's important that we really emphasize, and there are many myths of filtered tap water, and the benefits are really essential. We really want to emphasize on that. Our point number three will be to really discuss the need of the use of fluoridated toothpaste at all ages from almost from the first tooth in the mouth until you are 110 to really use this new consensus recommendation of the use of the toothpaste throughout the life course of the families and especially, the young child.

Lastly, as the age 1 visit is important that we really emphasize on the recommendations of the American Academy of Pediatrics, the American Academy of Pediatric Dentistry, the ADA, to really ensure a dental home by age 1. Even the pediatricians to refer us by age 1, not to wait any longer. Those are going to be our four topics. With that, we're going to be embedding them into some of the objectives that Sesame Street has with Head Start as well.

Limiting sugar to prevent tooth decay as you know. The bacteria with sugar release the one promoting this decalcification of early enamel lesions with acid. We tell the little kids to have the sugar box in there that when you feed them with all the sugars that you have through the day is going to create some acid. The acid, we don't tell them, maybe, they eat much sugar, they have to go to the bathroom and have to do number one, pee-pee. That is really some acid is going to really be calcified and make the holes new tooth. That's the story we tell for a three or four-year-old. They all want to go brush their teeth right away.

You know, for the reminders for those who know, the Steffens Curve or really the pH in the mouth is really the environment has much to do with the creation of these lesions due to the acidity of the mouth, the longer of frequency of exposures that we have throughout the day, especially when children are being fed many, many multiple times or three meals a day plus many snacks, you really create that the pH will drop down to a critical pH of 4.8 or 4.5, which is very acid. Everything below 7 is very acid, everything above 7 is very alkaline.

The idea is not to really allow this very acidic environment in the mouth throughout the day of the child. To really give them respites. Whenever you have any stimuli of any sugary foods or drinks, or any carbs will have to have these kind of decalcification of the enamel that will last anything from 20 to 30 minutes to go back to the neutral pH. It's an important thing to take into account. Less frequency and you don't mind the quantity, but less frequency throughout the day is essential. To drink between the meals as well.

There's very specific new fruit juice recommendations, as you know, I really want to make sure that you emphasize to the families the need, which is now from a really recommendation from the World Health Organization to reduce sugary foods and drinks in children under 3 years of age. These are some of the specific recommendations analysis between ages 1 to 3, serve no more than 4 ounces, it goes a little bit higher. Try to do no artificial sugars with 100% fruit juice, specifically, in a cup, not in a bottle. To really make sure that families know that the chances of getting real fruits instead of juices will be so much of a benefit in their diet and nutrition. Of course, limiting snacks with added sugar is something that we really emphasize as well.

Make sweet treats, not every day. Food, especially, we saw through COVID that all these families that they were sheltering in the households, they were using food especially, sugary foods and drinks for their children to keep them just to keep them distracted. Try not to use food as rewards for behavioral change, and comfort children with hugs kind words and really engage with them in coloring books or something that you can do throughout the day to engage them and have some bonding experience with the parents. There is this one of these videos that we're going to play a little.

[Video begins]

Dentist Grover: Hello there, mommies, daddies, and dental health enthusiasts. It is I, your cute and lovable dentist, Grover, here to tell you what is to keep your kid’s teeth healthy and clean.

Toothbrush: Yeah. These are simple things you can keep in mind when at home with your kids.

Dentist Grover: That is right, my giant bristly friend. One tip is having your kids eat all of their meal’s upside down. That way, all the bad stuff just falls right off them. Go ahead and flip upside down, toothy. Show them.

Tooth: I don't think so.

Toothbrush: Dentist Grover, kids should eat anytime snacks like fruits and vegetables.

[Video ends]

Dr. Ramos Gomez: You see they're very cute, these amazing videos. All the resources will be available for you also. This one is on tips of good eating habits, especially with fruits and vegetables added to the diet. All the resources are here.

We're going to be sharing with you the tip sheets, the cookbooks, all these different resources available for all the kids and staff and families, and the videos that you can really play in its entirety. These are some of the specific things on point number one, which is really limiting sugary foods and drinks throughout the day and the month.

Point number 2, remember that drinking the water throughout the day is really, really good, the benefits of drinking water. We really want to promote tap water. People, especially from first, second, and third generation here living in the US are very fearful still from drinking tap water. We need to demystify this myth that is out there.

I'm a Mexican myself living in Mexico. You know that you cannot really drink water from the tap, and these are the families that they come to this country now and they don't realize that that's how most of the states and the counties, their water is safe, it's OK, and as long as they can really if they don't want to just drink it from the tap, they can filter it, they can use Pur, Brita, any of those filters that are out there, even the refrigerator filter to make them address the issues of fears they might have of drinking tap water in the US.

The idea of only water in sippy cups is important that we really address the issue of introducing water early on to the child before pops, before the fruit juice, before any of the fruit drinks to really bring them in as the essential liquid in the household every day. I know this is tough because I mean how could you balance into a soda or water.

This is something that we know that the longer that you wait until introducing the children to sugary foods and drinks, they were not going to be obsessed in asking them for more and more and more because the minute you give them a little bit, there's some papillae in the tongue, in the floor of the mouth that really crave sugary foods and drinks. The longer you delay the introduction of sugary foods and drinks, the better you'll be with that.

Make it fun, keep it portable, flavor it if you like, ice it, make it available, model it. As long as all the families, role models are really essential for drink tap water. There's this great video. I cannot show it in its whole entirety, but it was created by First 5 here in California, Potter the Otter [Inaudible].

[Video begins]

Narrator: Potter the Otter, a tale about water brought to you by First 5 Santa Clara County. Once upon a time, there was a little otter. His name was Potter, and he loved to drink water. Mama and papa otter would say, "Potter, drink water every day. Drink water for thirst. You should know, water is healthy. It helps you grow." Potter loves water. This is true. He wants his friends to love water too. Let's go on a picnic, he said.

[Video ends]

Dr. Ramos Gomez: Potter shows and shows other friends in the forest about drinking tap water. But you see the message really is that introducing the children early on to tap water from the families, from the parents and caregivers, it's such an essential message that hopefully will continue when the child grows up. These are some great resources that we can share with parents, with the Head Start staff. All these resources are available there to your click. They will be right there for you, as well as all these videos in its entirety as well.

Point number 3, brushing with fluoride toothpaste twice a day. This is really something we really need you to be advocates for children's oral health, to really introduction early on of fluoridated toothpaste. A lot of families are concerned about the child swallowing the toothpaste. Even some professionals out there still do not recommend it.

There were seven or eight different recommendations before 2014. Thank God there was a consensus meeting with all the experts with evidence-based science. The proof of the use of fluoridated toothpaste throughout the life course of the children is essential. This is the quantity, or the amount is what is going to change.

This is the picture in children under 3 years of age. They're going to use a mere amount, very teeny, tiny amount. But really the last thing that touches your child's teeth should be the fluoridated toothpaste, especially the night exposure to this fluoridated toothpaste will be essential. It's mere amounts for children under 3.

Then a pea size amount or half a pea size if the child keeps swallowing the toothpaste. Perhaps you can do half a pea size or the pea size amount for children 3 to 6 years of age until they can spit. This is very simple. There's only one recommendation, which is now universal use of fluoridated toothpaste throughout the day and throughout the night. Ideally, will be that twice a day, 2 minutes.

It's challenging for parents. If you think about brushing the child's teeth is the number one most challenging issue that parents deal with, regardless their socioeconomic status, their race, their education. No matter where it is, parents struggle with toothbrushing. We have many, many tips about the earlier that parents get into the toothbrushing habit, the better off they will be.

Because this is something very important. By the way, this is a broad question if any of you is interested in going to dentistry when they ask until what time or age that parents are responsible for their child's toothbrushing? The answer is 8 years of age. Between 7 and 8, 8 years of age when the child has the more capacity of doing it properly. When they can really maybe tie their shoelaces, that's a time when you can say, OK, they can do it on their own.

Can you imagine, a lot of parents are not really aware of this responsibility they have. I had a patient a few months ago, and very well-educated parents. I asked when I asked a question. How is the toothbrushing? Oh, Dr. Ramos, he brushes his teeth three times a day. He's wonderful. I said, but he's only 2 years old, what do you mean? I said maybe he plays with that toothbrush.

But to really brush them properly, you need really parental supervision and parental involvement until they're 8 years of age. Please, help parents to go through this process. We know the sooner, the earlier they start, the better off they will be. Make it fun. We show parents different positions, different steps they can take.

Wherever the parent is comfortable, if it's a single parent or if it's a family of two, you have to really be cognizant. Also, caregivers, if the grandparents are involved, make sure that you bring them to the visit they can really be aware. And we do tell, do we tell them, we show them, and we ask them to do it themselves we know that they really learn through the process of the toothbrushing.

This is really something we really want to emphasize. You guys can really make a huge difference for parents by holding their hand about this special thing. This is the video that has being watched by over a billion people in the world. Is very famous now, and I hope you all enjoy it.

[Video begins]

Elmo: [Inaudible] It's time to brush your teeth [Inaudible]

[Music playing]

[Inaudible]

[Video ends]

Dr. Ramos Gomez: Isn't that wonderful, Rocio? You want to comment on this video? How did you get all these amazing celebrities to do this?

Maria: It was interesting that we usually tape celebrities throughout the year. We told them we have this campaign to help children brush their teeth. Everyone said OK, I'll tape it with you. It was really interesting. It was one of the first the only campaigns that actually celebrities were like, yeah, I'll brush my teeth in front of the camera.

What you'll see here is if you see the kids, one thing that we tested was the idea of children feeling comfortable with having the toothbrush in their mouths. That’s why you see the kids modeling first. Then, there's a part of the video where the child says, and now it's time to give the toothbrush to my parents or to my caregiver. Then the kids are handing over the toothbrush for the parent to actually brush.

I would suggest in using this video, the first time around, let the kids, just like you said, play around with the toothbrush. Then establish this routine of handing over that toothbrush for the caregiver for the entirety of the video so that they're actually getting their teeth brushed for the amount of time that is needed. It's a video that has been watched many times. What is very interesting is that we have a lot of people posting their own videos while listening to the song. It is one of those songs that can be playing in the background just to make sure that children feel more comfortable with toothbrushing, particularly at the beginning.

Dr. Ramos Gomez: The music is amazing. How do you come up with a song it's catchy? I cannot get out of my head. I keep singing all day long.

Maria: It was actually one of our writers had this vision for the song. When we mentioned the idea that parents should be the ones brushing the kid's teeth, she didn't know. As you were mentioning, many parents do not know. She wanted to create something that both the kids and the parents could listen to that then the parents would learn that they need to do the takeover of the toothbrush and brush the kids' teeth.

Dr. Ramos Gomez: I know. This will be a great, great resource for all the Head Start staff and the teachers to really get involved and the parent advocates as well to use this video to share with parents about the relevance of helping their children until they're 8 years of age. Wonderful. Since English and Spanish, tomorrow we’re going to be showing the Spanish version as well. It's just a delightful song, and we cannot really get it out of our system. We're happy. I hope you guys all sing along with us in some of these. Thank you again.

Bedtime routines. It's important that we really emphasize, as we mentioned earlier, on really avoiding to put the baby to bed with the bottle or the breast or sippy cup. If you have to do it, because I know a lot of parents use this feeding pattern at night, at bedtime to put the child to sleep. Unfortunately, all the milk will stay in there.

If you remember that curve of Stefan that we discussed earlier about the pH, the acidity in the mouth would be much if the teeth are bathed in that milk. Therefore, if you have to do this, maybe try to continue with the recommendations of the American Academy of Pediatrics, which start weaning the baby from the breast or the bottle after 1 year of age. If you want to continue, at least do it responsibly, not do it whenever the child wants the bottle or leave it all night long but do it just with timing issues. Controlled feeding will be very, very important.

To put really a cloth, a wet cloth or to wipe the baby's teeth and gums just before they go to bed at least they have some protection without the milk in there. Ideally will be to maybe wipe the baby's gums and the teeth as well. A little bit of fluoridated toothpaste. The last thing that touches your child's teeth really, I cannot emphasize enough, the last thing that touches your child's teeth at night especially should be a little bit of the fluoridated toothpaste and brushing their teeth.

The American Academy of Pediatrics came up with this amazing Brush, Book, Bed, which is really to make sure that brushing is like a routine, like almost washing the baby's hands or changing their diapers. To start very early on, tooth brushing is not this weird event later on that are just introduced when they are 3 or 4, but they do it as soon as their first tooth is in the mouth.

To use it as a bonding experience, this could be something that the parents can really get close to that child and use this opportunity to read them a little story, perhaps singing a little song, and then brush their teeth, and then put them to bed. Children need structure and they need routine. The whole implementation and guiding resources about this Brush, Book, Bed from the AP, you can find it here as well. A tip about really encouraging parents and give them some support about this challenge in brushing.

This is another video that we have.

[Video begins]

Dentist Grover: Dentist Grover here to tell you it is very important that you have a routine with your children.

Dr. Ramos Gomez: A routine, yes.

Dentist Grover: This dentist prefers something very different.

[Singing]

Toothbrush: Dentist Grover. Dentist Grover.

Tooth: Not a dance routine, a nighttime routine.

Toothbrush: You know, to help kids get ready for bed

Dentist Grover: Of course. I knew that. I knew that. Yes, just trying to cover everyone out before bed. That is right, yes. Now, it is time for our nighttime routine. Brushy, bookie, nighty nighttime. Observe. Step one, brushy time.

Toothbrush: Use this thing to remind you how much toothpaste you should use.

Toothbrush and Mom: A tiny smear if under 3. If bigger, use the size of a pea.

Dentist Grover: Make sure to get the fullers way in the back. Don't rush when you brush. Brush for at least 30 minutes and a half then split. Then it's time for step two, bookie time. And the little tooth and toothbrush lived happily ever after brushing twice a day. The end. Oh, now, step three, nighty nighttime. Goodnight, Ariel. Good night, toothbrush. Good night, tooth.

[Video ends]

Dr. Ramos Gomez: That's sweet. It's such a nice video. Do you want to comment, Rocio, on it?

Maria: Yes. When the book came out, actually, we were wondering, how do we support that incredible book? Because we know that routines are so important for young kids to establish the habit of brushing their teeth at the end of the day. Inspired by the book, we came up with this video. Of course, Grover is not going to get it right. But Grover represents many of us who might make mistakes, but then learns that routines are very important, and routines can be as simple as these three steps.

From a parent perspective, it is helpful, of course, to see the routine and to understand how much toothbrush that you see, that that's a very specific beat in the video. From a kid's perspective, also seeing another child doing their routine is very helpful for them to get used to the fact that they might be doing their routine as well. One idea here for this video is repetition. If you have the child watch this video more than once, it helps also really establish that routine as part of what they should be doing. Repetition really does help children, particularly with these healthy routines.

Dr. Ramos Gomez: Absolutely. That's such an essential part of this whole idea of getting them started very early on. A reminder that make sure that they go all the way to the back of the molars, because sometimes they forget on those areas, especially on the upper lower south side. Then the lingual or the lower molars in the inside where the tongue is. Not to forget to brush the tongue. The tongue has so much bacteria, it's important to brush that tongue also and relieve and cleanse it out, especially at nighttime as well. A wonderful video, Rocio. Thank you for sharing this.

The resource, again. We have the tip sheets. The E-C-L-K-C, the ECLKC, we call them. It's an amazing resource the National Center on Health, Behavioral Health, and Safety with Head Start has really joined forces to really come out with these amazing resources for all of you. Please make sure you use them. There's infographics, there's posters, there's all kinds of information for parents.

Lastly, my dear friends, we're going to discuss a little bit about the age 1 visit. It's such an essential part because parents question, why do I have to bring my child at age 1? And the rationale behind it, think about it. In the first year of life of the baby, the parents are used to take them to the pediatrician an average of five to six to seven times in that 1 year of life for their baby’s wellness visit.

All we're asking them is to give us one of those visits for the baby wellness dental visit, where we will do risk assessment as you know. We can use any of the risk assessment that carries assessment tool that are out there, camera tools, if you like. But there's specific tools for prediction of caries risk reduction at age 0 to 3, 3 to 5, 6 to 12, 12 and above. Therefore, it's important that you use a risk assessment tool that you don't need to knee exam.

That really, remember this visit is basically for the parents to have an oral health structure in the radar screen, especially when it comes to their children. With what else we do, we do the need to knee, we track for any of those white spot lesions, which are the previous predecessors of any caries before that tooth gets blackened or gets the infection or the abscesses in there.

There's a lot of things we can really showcase to parents. To help them and assist them with fluoride varnish application. We apply the vitamins in the teeth, will be the fluoride. Then we're going to leave them with anticipatory guidance or counseling, which is what we really want the parents to leave them with. What are the messages, the take-home messages they can take with them.

There are things that we need to reemphasize that parents need to really engage the child with chewing the food, that will really help them to develop with their speech. Baby teeth are so important because they hold a space for adult teeth and also promote self-esteem. You cannot really have a child without good oral health and having total health. Oral health is a paramount, paramount indicator of total health. It's important that you really, really become advocates for baby teeth.

 

Because most of the parents are going to say, “but doctor, they're only baby teeth” Who cares? What they do not understand is whatever happened infection or amount of bacteria or issues with their mouth that develop in their primary dentition, in the baby teeth are going to continue with the mixed dentition or the permanent dentition. It's essential that you really become advocates for baby teeth and primary teeth.

We have this condition, it's called early childhood caries or early childhood cavities, which is any child under the age of five with already cavities that can really be very, very infectious. They can go into the pulp and cause a lot of pain and discomfort, infection, poor eating and sleeping habits. It's really very challenging because the child cannot stay still, they cannot be school ready. First and foremost, they cannot focus. We cannot really expect a child like this to really thrive in the school system.

You know, dental infection is the number one emergency that school nurses have to take the child out of school because of dental pain. This is something that we really want to avoid. We cannot really allow as a society to let any child go through life with dental pain or cavities like this. As I mentioned earlier, what happens in the age one visit is pretty much a visit for the parents to really guide them in good oral health. There is a bunch of videos, there's a lot of information about caries risk assessment, we look for any decay, any the calcification of the enamel.

Most importantly, we do a tell, show, do. We tell the parents, we show them, and then we let them do it for us. We let them demonstrate, how are they going to brush their child's teeth at home? How are they going to be dealing with a screaming and crying child that maybe don't want to be having the toothbrush in their mouth. How to make it nice with the song. With maybe the Elmo toothy toothbrush, a song, or something that you can really give them to distract them so they can be very keen on the challenging of tooth brushing.

We're going to discuss the fluoride needs, that are relevance of fluoride. We live unfortunately in a very anti-vax and anti-fluoride society and community. We need to really address the issues with evidence. Address the fears that parents might have about the need for fluoride toothpaste and the need of fluoride varnishes or topical fluoride in the dental practice or in the professional practice as well.

Oral habits, teething, and eating habits was very fascinating to me to hear. Some data here in Los Angeles, in California where through COVID, the number one emergency that parents took their babies to the emergency room was for teething, if you can believe that. Teething is something we need to address as well. Take out all the myths that exist about teething. That high fevers or diarrhea or all this stuff is proven to be really having these teething issues. It's important that you take those myths away. To really talk to parents about what to expect.

The biggest challenge you're going to tell me, but Dr. Ramos, how are we going to get dentists to see my 1-year-old or the 1-year-old in our Early Head Start programs? There are amazing community clinics. There's some FQHCs that stand for Federally Qualified Health Centers. You can look at any of these websites that were showing here.

There's a bunch of free clinics. If you live in the proximity of a dental school, we all welcome 1-year-olds in our practices, in dental school, especially in the pediatric dental programs. There are some mobile dental programs. But if anything, just go to your search engine and look for FQHCs or Federally Qualified Health Centers, and I can assure you, there is one around your neighborhood that you can find near to you.

If for any reason they say, we don't take your child until they're three. You say, no, we know that we need to see them, you can guide us that child doesn't come with you with pain and infection and suffering. These are some of the specifics of the four very specific recommendations we're giving on the objectives for the course this morning.

[Video begins]

Dentist Grover: Two days, Snazzle. Of course, you can take toothpaste and a toothbrush on the way out.

Toothbrush: You have to clean up your teeth.

Dentist Grover: Ah, there goes another happy patient.

Toothbrush: Yes, Snazzle has been coming to this dentist's office since he was 6 months old.

Dentist Grover: Yes. Oh, look, here is a picture of his very first visit. Ah, the memories. The time for a child's first visit to their cute and fuzzy neighborhood dentist should happen when do we send the postcard reminders?

Toothbrush: Between 6 months and their first birthday. After that, they should visit twice a year as they grow.

Dentist Grover: Yes, thank you my not little dental assistant.

Toothbrush: No, Snazzle you visit the dentist twice a year, not twice a day.

Dentist Grover: Isn't this nice that you love coming to the dentist, though? Get your toothpaste. You can have poison berries. [Inaudible] Just next time, OK? Next time.

[Video ends]

Dr. Ramos Gomez: We hope we can have better patients. You want to comment on this break?

Maria: Yes. You’ll notice that in the video, we said from 6 months to one year because the message is by one, by year one. If we said only by year one to families, then they will go a year and 6 months. What we are doing here, because this is a much wider audience, when you're explaining to families, one-on-one is one thing. When you say wider audience, you expand the range so that children actually go to the dentist by year one. That's why you see that difference, a slight difference in the recommendation in the video.

It shows one of the things that we found with parents is that they were wondering, after that visit, what do I do? How many times? And you were mentioning, Dr. Gomez, that when it comes to pediatric visits, there is such a routine pediatric visit. Even those need support for families to know when to go to the pediatrician.

But because the ones for dentistry are a little bit more far apart or there's not enough information out there for most families, they don't know when to do the follow-ups. It's important, like you were saying, that first visit is important for families to know what to expect moving forward. If they make the routine from the very beginning of going every 6 months, then they're more likely to stick with it as children grow older.

Dr. Ramos Gomez: I know. This is such an important point you raised because that's why the initial, step one of the H1 visit is a caries risk assessment, which we're going to be finding Johnny needs to come and see us every month because they are high risk or extreme high risk of getting decay in the next few months or if Rosita has to come in 3 months or if Paolo has to come in 6 months. We really are tailoring a very individualized patient-centered approach based on the child's risk. Their diet and nutrition is assessed as well.

We look at the risk factors, that protect factors, and then the clinical findings. The dentist, the dental providers, dental hygienist, dental assistants can now really tell and assist with the periodicity scale of how often we should be seeing that child in the dental practice. This is very good information. Information to share with parents, we have these wonderful, wonderful tools, understanding why baby teeth are important. Finding a dental clinic for your child. I know this is such a big issue. You're going to say, it's hard to find access to dental care. But there are resources out there.

I'm thrilled to tell you that community health centers, these FQHCs are really an essential part of a dental home, a medical home where the children can really go and attend. They're wonderful partners with Early Head Start and Head Start as well. To really promote this visiting the dentist by age one is such an essential part of our recommendations that we hope that you guys all become advocates. Now with this, I want to really have you all repeat with me in a moment. I'm not sure if you can speak or not. I'm going to count one, two, three. Say, "2 is too late," all in unison. If my colleagues here can help me do that, let's work together to keep that next generation free from tooth decay. Let's see. I'm going to say, one, two, three.

Colleagues: 2 is too late.

Dr. Ramos Gomez: Don't ever forget. That’s a great message we can send to parents, to teachers, and to the whole Early Head Start program. With that, I want to thank Head Start office, the main office headquarters. I want to thank all my amazing colleagues that really get — it was a village approach and a team to get this done. Thank you to all of you. with that, I'm going to leave now Beth for some Q&A for us to go through this.

Beth Lowe: Hi, everyone. My name is Beth Lowe. I'm a part of the oral health team at the National Center on Health, Behavioral Health, and Safety. I'm going to help out with some questions. Some great questions that have been coming in during the presentation.

I'm going to start with — actually, this is a question that I had never heard before, and I'm going to direct it to Dr. Gomez. I think it's a great question because it is something that will come up time after time. This is on the limiting sugar part of it. We're talking about drinking water. Would rinsing with pH-balanced water help to bring back the pH of the mouth after a meal or a snack or any time anybody eats something during the day?

Dr. Ramos Gomez: Of course, those are the tough questions. There's no really evidence of that. But if that makes you feel good, ideally would be to try to control the amount of frequency of the feeding practices throughout the day. As I mentioned to you, I mean, we have plans. Tell me, I'm assuming you give breakfast, lunch, and dinner those are three meals in a day, how many snacks in between? Most of the parents will tell you two, right? Between breakfast and lunch and lunch and dinner. Those are five.

Besides that, how many intakes besides milk and water, what else does your child drink? If they tell us juice or pop or fruit punch or anything, we add those. Let's say they say two of them, that's a seven. Everything above five or six should really raise a red flag because we're trying to really make sure that the pH is really done naturally. The mouth is very — saliva is a buffer capacity to keep the pH at seven, not very alkaline and not very acid.

Whenever we introduce anything in our mouth let's say if you gave me Beth notes that I love M&Ms, and she sent me a bag of M&Ms. I haven't had any breakfast, nothing, Iet's take an M&M now, my pH of seven is going to drop to 4.5, 4.8. Let's say I just took one M&M, it's going to take 20 to 30 minutes to get back to my pH of seven. Can you imagine if I take an M&M every five or 10 minutes.

Frequency versus quantity is an essential piece of this whole equation. Try to limit the amount of intake throughout the day and the night of this child to really level up the pH on top of giving them as much as they want to eat and then trying to freshen up with pH-level water, which I don't think people have too much access to begin with.

Other important note, Beth, here to say, if you guys are going to use filters, because that's a very important question, please use any filters, per Brita or any of the natural filters out there. The only one that will remove what do we want our tap water to have? Because it has calcium, phosphate, and fluoride-enhanced bone formation and teeth formation as well and protects them in this systemic approach.

If you use that one, there is a very costly reverse osmosis filter that takes everything it gives you that distilled water, you don't have to spend money it's like $350 at a time. You don't have to spend that money in those reverse osmosis because that will take everything away. Will diminish the purpose of exposing the families to tap water.

Beth: Dr. Gomez, in that same vein, there have been a couple of questions about fluoride. A lot of parents and some Head Start staff are concerned about issues with fluoride. This is kind of a two-part question. One is, at what age should children start to be brushing their teeth with fluoride and why? Then the other one is, how do you help parents understand the importance and safety of fluoride?

Dr. Ramos Gomez: Very good. It's a very important question. As you know, we had a big consensus. I mentioned earlier, there were seven or eight different recommendations. It was all over the map, there was much confusion. The ABA gathered a whole consensus expert on evidence-based science on scientific evidence on clinical trials on the exposure of fluoridated toothpaste. The benefits, risks, and you name it.

The consensus is published, and it's a very big paper for all of us. It's a pioneer paper in dental research, where they really show proof this consensus meta-analysis of all the data that was out there in the world to come up with a benefit. The recommendation, the total recommendation universal use of fluoridated toothpaste from the first tooth in the mouth until you're 110, the idea is that you're going to control just with a smear under 3 years of age to really prevent this whole issue of fluorosis.

Fluorosis is when you have some discoloration of the enamel in your adult in your permanent teeth. That's why people are afraid of this fluorosis. In some areas where fluoride is endemic like in Mexico, in Central America, or India or Africa, there's some areas where we have endemic fluoride in the water. It has huge quantities. Some people have this fluorosis.

Let me tell you, for one case of fluorosis that we see, we see 1,000 cases of early child cavities. It's something that we should not be really concerned about, number one. Number two, there is this very conclusive evidence that people should really rely on. We can share that article any one of the audience as well to really ensure that this mere recommendation is very well proven to be effective. It's important that you start this habit very early on. Rocio mentions how Head Start and Sesame Street really work on early programming, early introducing habit structure to families at a very young age of these children. The sooner they can introduce this, the better it will be.

The second part of the question is something we're learning from the pediatricians. The pediatricians are struggling like us as pediatric dentists on the anti-vax parents because the same anti-vaccine parents are the anti-fluoride parents. You just have to address their fears as and where they get their sources. I mean, it's a process.

Now our residents have a whole technique that we train them on how to really address these issues when they come to our clinic. We cannot demystify like, oh, no. I don't know what you're telling me. You have to be very respectful and ask them, where is this information coming from? They will tell you, they Google something on the internet or something.

The latest, I had a parent to tell me that fluoride was causing pituitary cancer. I never have heard of that one. It was my first last year. you name it. There's many fake news about this and much misconceptions. You as a parent, where do you get your information from?

I say, well, let me tell you, can I just get your permission to share some of the sources that I have from the American Dental Association, the American Academy of Pediatrics, not even the dentists, the pediatricians, and also the American Academy of Pediatric Dentistry? I can share some of those resources that are clinical evidence findings. if you can share, I can send them to you. if you want, we can discuss it next time and take small, incremental steps to nudge them on their behavior of acceptance. Because you cannot really force any parent to things that they cannot do.

Beth: Great. Another question that has come in is, are there any special considerations for fruits that are high in natural sugar or acidity? Should certain fruits be limited to children to promote good oral health?

Dr. Ramos Gomez: Rocio, you want to take that one or —

Maria: Well, our materials were promoting healthy fruits and vegetables. They're just eating fruits and vegetables. What we actually encourage is because we want to promote that is to really look at, rather than the sugar content or anything like that, it's much more really enticing children to want to eat them by looking at the colors, by noticing their crunchiness, and making it fun. Because that is the main issue. The idea that a healthy body and healthy teeth. The head is part of the body. Anything that will make your body healthy is going to help in the long term for your teeth.

What you really want is for children to be eating those vegetables and those fruits. We know that many children, unfortunately, if they're not introduced earlier to some of these foods, they're less likely to eat them as they grow older and they make those choices. The earlier that we can really start encouraging them to eat them, the better.

Dr. Ramos Gomez: Yes, and for us, just to remind you that in the pediatric dental world, we just ask parents to stay away, especially early on of sticky dry fruits like raisins, cranberries. Anything that sticks in the child's teeth that will stay there for longer periods of time that will cause the pH to drop constantly, and the acidity will continue in the mouth. We want them to stay away from all these sticky fruits that can be they're available for them.

Maria: Crunchy is important. Bright. Like, raisins are not bright. There you have it.

Beth: That's great. Let's see, I think we answered most of the questions about fluoride. There's one question that came in about why should children see a dentist starting at age 6 months? The person that asked that question thought it was a year. If you just clarify that a little bit.

Dr. Ramos Gomez: The policy recommendation is very clear, this is between 6 months and 12 months of age of that child, why? Because between 6 and 12 months is when the early eruption of some of the anterior incisors, the lower anterior incisors will come approach.

The dental provider can really address the issues of teething, of what to expect, of cleansing the gums, even though there is no teeth in the mouth. Starting the early oral health and hygiene, introduction to parents and families will be essential and ideal.

We don't need to have a baby with teeth to bring them to the dental environment or dental practice, because we will welcome them. Hopefully all the new providers of the future, the ones who are training at the moment, even general dentists and the pediatric dentists of the future in the next 34 years are really trained now to welcome with open arms babies from 6 to 12 months of age.

And if not, they better be aware that that's going to really deteriorate in their practice. Because if they do not welcome these babies, guess what? Parents are very, very funny with their children. First, they bring their children to see that new dentist in town, then they bring their own parents, their uncles, their relatives, their cousins, their compadre, their commander, whoever their godfathers are. Then if they are happy with the dentist, then they bring them themselves to go there. They use the children as Guinea pigs. They better be welcoming of these young babies early on because it's a wonderful way to build a nice practice and a dental home for not just the child but the families as a whole.

Maria: There's also, it's important to notice that when it comes to there's very good reasons from a policy perspective for that to be the case. From a messaging perspective, there's also very good reasons to suggest the 6 months to one year. Again, if we say by one year, people interpret in many different ways. If you say from 6 months to one year, then they know, oh, this it has to be when they're young. They make that realization from just a messaging perspective. Of course, there's many, many more reasons that Dr. Gomez was mentioning. But from a messaging perspective, it's important to highlight that for young parents.

Dr. Ramos Gomez: Excellent.

Beth: That's great. Dr. Gomez, one of the things that I don't think people necessarily understand, especially when they're looking at when to take a child to a dentist, that the program performance standards indicate that a child should be up to date with the EPSDT schedule for the dental periodicity schedule. Can you explain the difference between the dental periodicity schedule and the well-child schedule?

Dr. Ramos Gomez: I think that the well-child if I understand your question properly, I believe that the wellness schedule is really now in addition to the other milestones or the vaccinations. They really have added a dental piece in there, which we're very thrilled and happy that the pediatricians are doing that to remind them of when is the good time by 6 to 12 months of age to start their first dental assessment. Or to at least refer the child for a dental home by age one.

Ideally will be that we have this incoordination. I mean, we have now different clinics, we call it interprofessional, education, and practice, where we are in the wellness baby clinic, where the pediatricians were right there sitting alongside with them that babies can be seen by the pediatrician for the wellness baby visit and for us to see them for the wellness dental baby visit. The idea is that we both are in integration in there. What are the messages that we're leaving them?

Part of our oral health literacy piece is to really come up with a very graphic self-management goals. We have a chance to show it here today, but if you can go the resource on self-management goals. We ask parents, if there's two things you can do for your child for the next visit, what those two things you can do? We try to use motivational interviewing to get them engaged into this oral health behavior.

Think about it, we as providers, we spend no more than two hours average in one year with that child. Our really strategy has to do with the parents. The parents will spend 10,000 hours with that child in that one year. Whatever we need to really create this parental engagement to have this oral health savviness and to feel supported by us in a team approach, where they're almost like a health coach, to really get the parents early on in this strategy of good oral health and hygiene and diet and nutrition, which are the two key messages we send out.

But it's really a labor of love and takes a village. We really rely heavily on Head Start. Head Start, when they used to have their toothbrushing programs throughout the country, which I hope and I pray that we still go back again, was one of the most amazing, incredible opportunities of role modeling for these children. Because they will take this and they will go home and says, mommy, daddy, my teacher at Head Start, he's brushing my teeth. Why don't you brush into me at night?

These are the kinds of things that we really have to really address, that it's so essential, this amazing labor of love that Early Head Start staff and Head Start staff are doing with toothbrushing in the lunchroom and in the classroom is such an essential practice that we really need them to embrace, to really welcome back, and to really get back to toothbrushing as soon as they can. Because we really need you to help us with this incredible effort.

Beth: There are a lot of great resources on ECLKC to help you with that as well.

Dr. Ramos Gomez: There you go.

Beth: I have one persistent question that keeps coming back up, so I'm going to ask it.

Dr. Ramos Gomez: Well, I hope it's not a tough one, now.

Beth: No, I don't think it's a tough one. It’s, “as children age or get older, do you recommend that they rinse their mouths with salt water?” Not sure exactly.

Dr. Ramos Gomez: What I meant bicarbonate water, I don't know if later It really says a lot about the myth of pH. Again, addressing I think it's maybe the same person that wants to have a neutral pH water. Bicarbonate brings alkaline. It brings you acidity of your mouth.

I mean, I know that my parents used to like to do that. It's kind of a telltale sign. If it works for you, whatever works for you. I don't think there's evidence on any of that. If it works for you, I think it will hinder or will cause any harm to the child or themselves.

It's really just good for me, if you can just focus in those two very specific habits of the regular tooth brushing with fluoridated toothpaste, at least the last thing that touches your child still is fluoridated toothpaste. Secondly, follow the WHO, really recommendations or reduce or to avoid any sugary foods or drinks before the age of 3 will make a huge, huge dent in promoting and really engaging in cavity-free generations.

We have to really empower parents to know that it's upon them to have a child with no cavities, with no dental pain, with no dental suffering for the rest of their lives. This idea that I had a mother the other day that we said, “I'm so sorry, your child has two cavities.” She embraced me and she said, “Dr. Ramos, I'm so happy.” She applauded and said, “I'm thrilled. At her age, I had 20 cavities.”

This whole idea of the parents knowing that they can have a child-free generation is something that we need to really address and advocate, especially all of us in Head Start and Sesame Street, the great effort that you guys are doing to really promote this well-being, to keeping healthy teeth, healthy air, it's something that we can address with very simple approaches. But it takes time, it takes effort, and it really takes us to really engage these families very early on with early programming and early instructions and coaching them through life course.

Maria: At first, we're starting early. We're trying to start early. Keeping it simple in the messaging. Like you were saying Dr. Gomez, really focusing on these messages that you've presented is very important. One of the things that families were telling us when we started all of this was that they were so confused with all the different messaging that was out there. Keeping it simple to these very specific messages makes a big difference.

Dr. Ramos Gomez: Absolutely.

Beth: Thank you much. That's all the time we have for the questions right now. Maybe I can give us an idea of what we'll do. There are quite a few other questions that have come in, some of which I'd like to address in the future and help out with that.

Dr. Ramos Gomez: I think that is going to talk about evaluation now.

Nydia: Yes, I'll answer all the questions about the evaluation, as well as the other questions. All the questions will get answered, do not fret. But I want to first say thank you, once again to Rocio and to Dr. Gomez for this very important oral health information. If you have more questions, you can go to my peers or you can write to health@ecetta.info. The evaluation URL will appear when you leave the Zoom platform.

Remember that after submitting the evaluation, you will see a new URL. This link will allow you to access, download, save, and print your certificate. You can subscribe to our monthly list of resources using this URL. You can find our resources in the health section of the ECLKC or write us, again, it's at health at ecetta dot info. Thank you once again to Rocio and Dr. Gomez and everyone backstage. Thank you, participants, for your participation today. Thank you.

Dr. Ramos Gomez: A pleasure being with you. Thank you again and thank you for all the amazing work you guys are doing. Head Start and Sesame Street, we're thrilled to have you. Thank you.

Nydia: God bless. We're here to support all of you.

Dr. Ramos Gomez: God bless.

Nydia: Take care.

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