Public Health Department Policy & Procedure Manual Example

Procedure for Administering the Mouth Rinse Program

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Procedure for Administering the Mouth Rinse Program

The following instructions are merely guidelines, you may use any method that will accomplish the same purpose.

Mixing the Fluoride Solution

The solution should be prepared in advance. It requires about one minute to do. The exact instructions for mixing are on the label of each jug. They are simple and easy to follow.

Preparation for Rinsing

Each child is provided a cup filled with 10 ml of the solution and one paper napkin (Kindergarteners receive 5 ml). There is a different pump for each amount to dispense the exact amount of liquid. The method of distribution can be chosen by the person in charge of the program:
Method 1: The distribution of the cups and paper napkins and filling the cups with the fluoride solution is accomplished while the pupils are at their desks. One of the pupils in the classroom will distribute the cups, and another pupil will distribute the paper napkins, one of each to every pupil. The teacher will walk from desk to desk with the jug of solution, place the jug on top of the pupil’s desk, and with one stroke of the pump fill the cup with the appropriate amount of the solution.
Method 2: The filled jug with the fluoride solution is set up on the table or teacher’s desk together with a stack of napkins and paper cups. One pupil is in charge of the cups and another is in charge of the napkins. The teacher is in charge of the jug. The pupils form a line in front of the table or desk. Each pupil receives a cup and a napkin, after which the cup is then filled with fluoride solution by one stroke of the pump. After the cup is filled, the pupil returns to his or her desk until everyone is seated

The Rinsing Process

  1. When all children have their filled cups and napkins in their hands, remind them not to swallow the solution. If a child were to accidentally swallow the 10 ml of fluoride solution, it would produce no adverse reaction.

  2. Have all the children slowly empty the contents of the cups into their mouths and begin to rinse for one minute.

Correct Rinsing

To rinse correctly with maximum results requires the swishing of the solution all around the teeth, so that the liquid is strained back and forth through the spaces between the front and back teeth. When correctly done, the cheeks and lips will puff rhythmically. Some children may just shake their heads back and forth without accomplishing anything; they should be watched and instructed on proper rinsing.

The first rinsing exercise should be done as a practice session using water. Instruct them exactly what to do while they are rinsing.

Have a timepiece with a secondhand. Supervise the rinsing for the full 60 seconds either by instruction or by rinsing with the class.

When the mouth rinsing has ended, direct the pupils to expectorate the solution back into the cup, blot their lips with their napkins, and slowly stuff the napkins into the paper cups to absorb the liquid. The cups should then be deposited into a plastic lined waste bag. The entire procedure can be accomplished in 5 or 6 minutes.

Then children should be instructed not to eat or drink for 30 minutes after the rinse. Therefore, do not schedule the rinse immediately before lunch. The most beneficial time for the rinse is the first thing in the morning, shortly after the children have brushed their teeth.


POLICY TITLE: Fluoride Sealant Program



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To reduce the proportion of school-aged children who have dental caries experience in permanent teeth by increasing the number of dental sealants on their teeth and promoting oral health as part of the child’s total health.

  1. The Pepin County Sealant Program will serve Pepin County public and private school second grade children with signed parental/legal custodian/guardian medical history/consent forms in schools with a second grade enrollment of greater than 20 children.

  1. The administration of the sealant program is the responsibility of Pepin County Health Department under the direction of the Agency Director/Health Officer or his/her designee and the medical advisor.

  1. Only a state-licensed dental hygienist or dentist may apply dental sealants for Pepin County Health Department.

    • A state-licensed dental hygienist practices as an employee or independent contractor consistent with s. 447.01 (3), 447.06 (1), (2) (a) (2,3,5) Wis. Stats.

    • A state-licensed dentist practices consistent with Ch. 447 Wis. Stats.

D. Currently clients are transported by Pepin County Health Department to the offices of volunteer dentists. Permission to transport students is obtained prior to transport.

  1. The Agency Director/Health Officer will assign support staff as necessary.

  1. Only a state-licensed dental hygienist or dentist may apply dental sealants for Pepin County Health Department.

  2. A state-licensed dental hygienist practices as an employee or independent contractor consistent with s. 447.01 (3) and s. 447.06 (2) (a) 2., 3. and 5., Wis. Stats.

  3. A state-licensed dental hygienist practices consistent with Ch. 447 Wis. Stats.


  1. See Appendix B for a copy of consent forms and screening forms.

  2. This program uses sealant material that is an approved United States Food and Drug Administration device.


1. Record Keeping:

A. A signed copy of informed consent and a signed and dated medical history and screening form must be kept in the individual’s health record.

B. Using the medical history, prior to sealant placement, caries risk assessment and oral screening is conducted by a state-licensed dentist or dental hygienist. The following information will be recorded.

  1. name, date, birth date, grade, special health care needs status

  2. caries experience, untreated caries, dental sealants, treatment urgency (urgent, early, or no treatment needs)

  3. individual teeth indicated for dental sealant placement

  4. teeth and surfaces that have received sealants

  5. name of licensed individual conducting screening and sealant placement

  6. comments and indication of referral
    1. The need for dental sealant placement by a state-licensed registered dental hygienist or dentist will be determined consistent with the Workshop on Guidelines for Sealant Use: Recommendations and ASTDD Basic Screening Survey.

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