Program Instructions (PIs)—2006

Oral Health—Revision (ACF–PI–HS–06–03)

PROGRAM INSTRUCTION:

TO: Head Start and Early Head Start Grantees and Delegate Agencies

SUBJECT: Oral Health

INSTRUCTION: This Program Instruction supersedes the provisions of ACF-PI-HS-06-02.

This Program Instruction explains the Office of Head Start’s policies and expectations regarding grantee compliance with selected oral health requirements of 45 CFR 1304 Subpart B-Early Childhood Development and Health Services.

Beginning February 2007, the Office of Head Start (OHS) will monitor compliance with 45 CFR 1304.23 (b) (3) by reference to the following minimum requirements. Head Start grantees and delegate agencies will be considered in compliance with the requirement to effectively promote dental hygiene in conjunction with meals by ensuring the following:

• For children age two and over
  Once daily, after a meal, Head Start staff (or volunteers, if available) should assist children in brushing their teeth using a small smear of fluoride toothpaste.
• For children between one and two years of age
  Once daily, after a meal, Head Start staff (or volunteers, if available) must brush children’s teeth with a soft bristled toothbrush, using a small smear of toothpaste that contains fluoride.
• For infants under the age of one
  At least once during the program day, staff or volunteers must wash their hands and then cover a finger with a gauze pad or soft cloth and gently wipe infants’ gums.

BACKGROUND:

Head Start and Early Head Start health services focus on prevention and early intervention and are based on the premise that a child must be healthy in order to be ready to learn. Good oral health for infants, toddlers and pre-school children serves as a precursor to adult oral health and is essential for a child’s behavioral, speech, language and overall growth and development.

In conformance with Head Start’s philosophy of prevention and early intervention, and identifying possible oral health concerns as early as possible, 45 CFR 1304.20 (a)(1) requires the following activities must take place within 90 days of entry into the program:

• Determine if a child has an ongoing source of continuous, accessible health care (includes a dental home); 1304.20 (a)(1)(i)
• Obtain a determination of whether a child is up to date according the State’s EPSDT schedule, including dental; 1304.20 (a)(1)(ii)
• If a child is not up to date, assist parents in making necessary arrangements to bring their child up to date; 1304.20 (a)(1)(ii)(A)
• If a child is up to date, ensure the child continues to follow the State’s EPSDT schedule 1304.20 (a)(1)(ii)(B)
• Develop procedures to track the provision of health care services; 1304.20 (a)(1)(ii)(C)
• Obtain or arrange further diagnostic testing, examination and treatment by a licensed or certified professional for each child with an observable, known, or suspected health or developmental problem; 1304.20 (a)(1)(iii)
• Develop and implement a follow up plan for any condition identified; 1304.20(a)(1)(iv)

Although follow up plans must be developed and implemented within the required 90 day time frame, treatment services do not have to be completed within 90 days. See 1304.20 (a)(1)(iv).

Grantee and delegate agencies operating programs less than 90 days, such as migrant programs must complete the above processes within 30 days of a child’s entry into the program. See 1304.20 (a) (2)

Dental Home

45 CFR 1304.20 (a)(1)(i) requires a determination to be made if a child has an ongoing source of continuous, accessible health care; i.e., a medical home. This includes dental health care. The American Academy of Pediatric Dentistry (AAPD) defines a dental home as a source of continuous, accessible, comprehensive, family-centered, coordinated, compassionate, and culturally effective oral health care delivered or directed by a professional dentist. In many communities, identifying a dental home in a timely manner can be a challenge, when there are a limited number of dentists who will see children under the age of five or that will accept Medicaid/EPSDT families. As a short term solution, Head Start and Early Head Start programs can bring providers on site or use mobile dental vans to assist parents to obtain examinations and/or begin treatment services while at the same time working with the family to secure an ongoing source of dental care for their child.

Determination by a Health Professional

A health professional that makes a determination as to whether a child is up to date on a schedule of age appropriate preventive and primary health care, including dental, are staff or consultants who have training and experience in public health, nursing, health education, maternal and child health, or health administration and are familiar with the State’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) schedule.

State EPSDT Periodicity Schedule

For Head Start, a State’s EPSDT schedule is the baseline minimum schedule of preventive and primary health care for all enrolled children, including non-Medicaid/ non-insured children. All Head Start staff involved in making a determination if a child is up to date (see next section) must have a working knowledge of the most recent state Medicaid EPSDT requirements for dental services. The frequency of dental examinations and who can perform them is determined by the State Medicaid program and not the Office of Head Start. Further information about the Center for Medicaid Services (CMS) dental services can be found at: http://www.cms.hhs.gov/MedicaidDentalCoverage/

Children Determined Not to Be Up to Date

If the determination by a health professional shows that a child is not up to date according to the state EPSDT periodicity schedule, programs must assist parents in making the necessary arrangements to bring the child up to date. Assistance to parents includes but is not limited to: providing education to parents to help them understand the importance of having their child see a dentist; identifying dentists in the community that accept Medicaid or other forms of insurance, or that provide free oral health care; providing or arranging for transportation to the dentist; and providing or arranging for child care services. In instances where parents are unable to accompany their child to the dentist, Head Start programs with written parental consent can either transport the child to the dentist or have the dentist come to the center to provide services to the child. 1304.20 (a)(1)(ii)(A)

Children Determined to Be Up to Date

For children who are found to be up to date according to the state periodicity schedule, Head Start grantees must ensure that they continue to follow the recommended schedule of well child care, as required by 1304.20 (a)(1)(ii)(B).

Ongoing Care

In order to maintain a child’s oral health, it is critical that procedures for identifying any new dental concerns be implemented as required in 1304.20 (d). Staff having day to day interactions with children, such as bus drivers, teachers and teacher aides, family service workers, cooks, etc, must be familiar with these procedures in order to help identify children in need of dental care as soon as possible.

Dental Screenings

Dental assessments or screenings, as part of a primary care provider’s visit, are optional services for state Medicaid agencies. Unless specified by the state Medicaid EPSDT periodicity schedule, Head Start regulations do not require dental screenings. In an effort to address the shortage of dentists that accept Medicaid patients, some states use dental hygienists to conduct oral health assessments or screenings. These screenings do not replace the EPSDT requirement that a child be referred to a dentist by the age of three, unless otherwise specified by the State.

Medicaid State Plan

The primary goal for referring all children to a dentist is to establish a dental home for each child where they can receive comprehensive diagnostic, preventive, restorative and emergency care throughout childhood. A state’s Medicaid plan is the official document that defines how each state will operate its Medicaid program. The state plan addresses the areas of state program administration, Medicaid eligibility criteria, service coverage, and provider reimbursement. A copy of a state’s Medicaid plan can be found at: http://www.cms.hhs.gov/medicaid/stateplans/map.asp

Paying for Dental Services

Early Head Start or Head Start program funds may be used for medical or dental services, when no other source of funding is available. If a child is enrolled in Medicaid and there are no dentists available to provide services, then a Head Start or Early Head Start program funds can be used to pay for dental services. Head Start programs should document what efforts were made to find other funding sources and why the program decided it had no recourse other that using Head Start funds to cover required dental services. CFR 1304.20 (c)(5)

In conclusion, achieving optimal oral health for all children in Head Start and Early Head Start is a priority for the Head Start program. In addition to this Program Instruction, the Office of Head Start will be issuing an Information Memorandum on Oral Health. This Memorandum will include suggested strategies for implementing Program Performance Standards that support quality oral health services in Head Start and Early Head Start.

Please direct any questions on this to your Regional Office.

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