Health Manager Orientation Guide

Oral Health Promotion and Disease Prevention

Tooth decay is the most common chronic disease in young children. It is also a complex disease. Many factors protect teeth from tooth decay, while other factors may cause it. The key to preventing tooth decay is keeping a balance between these factors or, ideally, having more factors that protect teeth from tooth decay than cause it.

Three factors associated with the prevention of tooth decay include:

  • Fluoride
  • Healthy eating habits
  • Toothbrushing


A tray of neatly organized children's toothbrushes.Using fluoride is one of the safest and best ways to prevent tooth decay. Fluoride use reduces the development and severity of tooth decay, so it is important to help families understand its benefits.

Fluoride is a mineral that occurs naturally in the earth and is released from rocks into the soil, water, and air. Almost all water contains fluoride, but usually not enough to prevent tooth decay. Often, fluoride is added to community (tap) water supplies as a public health measure. This is known as fluoridated tap water. Most people get fluoride by drinking fluoridated tap water and consuming foods and beverages prepared with fluoridated tap water. This inexpensive approach requires little or no effort. Drinking fluoridated water strengthens the permanent teeth forming in young children’s jaws. Fluoride tablets or drops can be prescribed by dentists, physicians, and nurse practitioners if the public water supply or well water has low levels of fluoride or if fluoridated tap water is not safe to drink due to water-quality concerns. These two types of fluoride are called systemic fluoride because the fluoride is ingested, moving through the entire body system.

Fluoride varnish, gels, or foams can be applied to tooth surfaces to make them strong and resistant to tooth decay. It is applied to the surfaces of teeth that are visible in the mouth. Both oral and other health professionals can apply these topical fluorides to tooth surfaces.

Fluoride in tap water has a topical as well as a systemic effect. When individuals drink fluoridated tap water, some of the fluoride goes into the body (systemic effect) and some goes into the saliva, which washes the teeth and makes them strong and resistant to tooth decay (topical effect).

Silver diamine fluoride (SDF) is a form of topical fluoride that many oral health professionals use to slow or stop tooth decay. SDF is a colorless liquid that is applied to teeth with a small brush. It contains small amounts of silver, which kills bacteria that can cause tooth decay, as well as fluoride to slow down or stop tooth decay.

Because the application of SDF on children’s teeth is painless and does not require the use of local anesthesia or drills, it can be an ideal approach for treating tooth decay in children. This is particularly true for children who:

  • Are fearful of receiving oral health care.
  • Have difficulty cooperating with oral health professionals, such as children who cannot sit still or those with intellectual or developmental disabilities.
  • Need two or more dental visits for treatment for severe tooth decay.
  • Have extensive tooth decay that requires care under sedation or general anesthesia in a hospital operating room.

Care should be taken to carefully explain to families that areas of tooth decay will turn black after SDF is applied. When this is explained, most families accept that their child’s primary teeth will be stained black. Families are less accepting of black staining on their child’s front teeth. However, the use of SDF is often preferred on a child’s front primary teeth if the child cannot cooperate with the oral health professional or requires sedation or general anesthesia to treat tooth decay.

Tips and Strategies Related to Fluoride

  • During the program’s community assessment, determine if children’s primary source of drinking water is adequately fluoridated. For families without access to fluoridated water, encourage them to ask their dentist, physician, or nurse practitioner if the child should receive fluoride supplements.
  • If a child is prescribed fluoride supplements by their oral health professional or other health professional, document this information in the child’s health record. Check with the family periodically to see if they need assistance getting the prescription filled or setting up a routine to make sure the child takes the supplement every day.
  • Include documentation in a child’s health record when a child receives a topical fluoride application from an oral health professional or other health professional (at least once a year).
  • Encourage Head Start programs and families to use bottled water with fluoride if the local water supply does not contain fluoride or is not safe to drink.
  • If a child has untreated tooth decay, encourage the family to ask their child’s oral health professional if SDF can be used to treat their child’s tooth decay.

Eating Habits

Child eating healthy foods.Eating habits play a significant role in children’s oral health and overall health and well-being. Children who consume foods and drinks containing natural or added sugars frequently throughout the day are more likely to develop tooth decay compared with children who consume food and drinks that do not contain natural or added sugar. Head Start staff and families may not realize that many of the foods and drinks children consume contain sugar.

Sugar plays a key role in the development of tooth decay. Many foods, like milk and milk products, fruits, vegetables, grains, and processed and prepared foods, contain natural or added sugar. Bacteria that cause tooth decay break down foods and drinks that contain sugar to form acid. Each time a person consumes foods or drinks containing sugar, acid is in the mouth for 20 to 40 minutes. This acid bathes the teeth and breaks down the tooth’s strong outer covering (enamel) to cause tooth decay.

Children who eat their meals and snacks at scheduled times have acid bathing their teeth for much less time during the day than children who eat frequently or are allowed to graze throughout the day. Over time, children whose teeth are bathed in acid frequently are more likely to develop tooth decay.

Choosing healthy drinks is just as important as choosing healthy foods. Drinking water has many benefits, including strengthening teeth, moving nutrients through the body, ridding the body of waste, and promoting healthy weight. Plus, water does not contain sugar.

Unfortunately, many drinks contain sugar, including those that are frequently served to children. Fruit juice, fruit drinks, vitamin waters, energy drinks, and flavored milk all have natural or added sugars. When children consume drinks with sugar throughout the day, their risk for developing tooth decay increases.

Tips and Strategies Related to Healthy Eating Habits

  • Establish policies and procedures for serving healthy, safe, and developmentally appropriate foods and drinks and for serving foods in ways that promote oral motor skills, like using developmentally appropriate utensils, dishes, and cups.
  • Make sure enrolled children receive meals and snacks that conform to U.S. Department of Agriculture (USDA) requirements and that are high in nutrients and low in fat, sugar, and salt.
  • Make safe drinking water available to children during the program day.
  • Encourage families to:
    • Limit foods and drinks high in sugar to special occasions.
    • Avoid using food as a reward.
    • Comfort or reward their child with hugs, kind words, or non-food items such as stickers.

Learn More


Staff member brushing a young child's teeth.Daily brushing with fluoride toothpaste is effective at preventing tooth decay. Head Start recognizes the importance of oral health and its impact on the overall health and well-being of children and their families and on children’s ability to learn. This is illustrated by the inclusion of daily toothbrushing in the HSPPS (45 CFR §1302.43).

Staff can help children brush their teeth at the sink or at a table. Regardless of the approach, infection control that includes prevention of disease transmission — and appropriate storage of toothbrushes with no toothbrush touching another one — is always important.

Head Start staff can help children brush their teeth and develop positive oral health habits that will last a lifetime. Scheduling time for children to brush with fluoride toothpaste during the program day ensures that children brush at least once a day.

Tips and Strategies for Toothbrushing

  • Establish a regular protocol that ensures that appropriate staff, or volunteers, if available, help children brush their teeth with fluoride toothpaste once daily. Include policies and procedures for:
    • Acquiring, cleaning, storing, and replacing age-appropriate toothbrushes.
    • Storing and dispensing the proper amount of fluoride toothpaste based on the child’s age (rice-size amount for children up to age 3 or pea-size amount for children ages 3–6).
    • Rinsing toothbrushes and storing them in a holder that allows them to air dry (no toothbrush covers) in an upright position without touching another toothbrush.
    • Maintaining effective infection control that prevents disease transmission and cross-contamination of toothbrushes.
    • Maintaining hand hygiene for staff to prevent exposure to saliva and other body fluids.
  • Train Head Start staff and families on the:
    • Role of brushing with fluoride toothpaste in the prevention of tooth decay.
    • Proper amount of fluoride toothpaste based on child’s age to dispense on a child’s toothbrush.
    • Approaches for positioning a child to effectively brush their teeth and strategies for brushing an uncooperative child’s teeth.
    • Infection-control approaches for cleaning and storing toothbrushes in the program or at home.
  • Invite oral health professionals to contribute to lesson plans and to participate in family activities by answering questions and providing guidance on toothbrushing and other oral health issues.
  • Monitor the Centers for Disease Control and Prevention (CDC)’s guidance on toothbrushing and incorporate new guidance into program policies and protocols.