EAST CENTRAL REGIONAL HOSPITALDENTAL DEPARTMENT

LIVING AREA ORAL HEALTH CARE

TABLE OF CONTENTS

INTRODUCTION.............................................................................................................................. 1TOOTHBRUSHING.......................................................................................................................... 1SPECIAL ADAPTATIONS OF TOOTHBRUSHES FOR CLIENTS WITH UNUSUAL PROBLEMS. 3 Clients with Arthritis or Chronic Diseases of the Joints............................................................... 3 Clients with Cerebral Palsy or Central Nervous System Disorders............................................. 3 Client with Limited Arm Movement.............................................................................................. 4CLIENTS WHO ARE SEMICOMATOSE.......................................................................................... 4CLIENTS WHO ARE AT RISK OF ASPIRATION PNEUMONIA ..................................................... 5MOUTHWASHES............................................................................................................................. 5CARE OF TOOTHBRUSHES IN LIVING AREAS............................................................................ 5DENTURES...................................................................................................................................... 5 Cleaning Dentures....................................................................................................................... 6 Denture Brushes.......................................................................................................................... 6 Stains and Odors......................................................................................................................... 6 Hard Deposits.............................................................................................................................. 6REFERRALS TO DENTAL CLINIC.................................................................................................. 7LIVING AREA PERSONNEL ESCORTING CLIENTS TO THE DENTAL CLINIC........................... 7

ECRH Dental Procedures - Living Area Oral Health Care Page - i6/2004

INTRODUCTION

The handicapped and mentally retarded client frequently has complex dental problems such as sore gums, loose teeth, ill-fitting dentures, gingival hyperplasia, and an unclean mouth. Patience and skill are needed in persuading such individuals to take an active interest in their oral hygiene. Crippling and immobilizing effects of disease often make normal procedures for oral hygiene difficult or impossible. Health service personnel can help these clients with a variety of services that will insure improvement in oral hygiene.

Dental care includes not only periodic professional dental care by the dentist or dental hygienist, but also daily oral hygiene procedures. Both the client and direct care staff must work together in establishing and maintaining the cleanliness of the mouth.

TOOTHBRUSHING

The type of toothbrush is extremely vital to proper oral hygiene. The toothbrush recommended by the American Dental Association has:

1. A straight handle with flat or curved brushing surface.

2. Soft nylon bristles with rounded and polished ends.

3. A bristle head small enough to reach all areas of the mouth easily.

After each use the toothbrush should be:

1. Rinsed with clean, cold water to remove retained food and toothpaste.

2. Stored in a light airy place to dry thoroughly.

A method recommended by the American Dental Association for toothbrushing is as follows:

1. The teeth should be cleaned thoroughly at bedtime and, if possible, brushed after each meal.

2. Wet bristles of the toothbrush with water and place a small amount of dentifrice on them.

3. Place the brush on the outside tooth surface at about a 45 degree angle directed toward the area where the teeth and gums meet.

4. Press, so as to slide the bristles against the teeth at the gum margins. The tufts of the bristles should divide to "straddle" the gum margins.

5. In this position, use tiny back and forth or "vibrating" strokes, barely moving the brush and continuing to hug the gum margins and adjacent necks of the teeth, then sweep toothbrush up against teeth (lower teeth) and down against teeth (upper teeth).

6. Repeat the placement and motions on 2 or 3 teeth at a time throughout the upper teeth. Brush the lower teeth in the same manner.

7. The inside surfaces of the back teeth require the same applications and motions as the outside surfaces.

8. Brush the inside surfaces of upper front and lower front teeth by holding the brush against tooth and gum surfaces, jiggle brush at gums (massaging gums) then brush up on lower teeth and down on upper teeth.

9. Chewing surfaces require short back-and-forth scrubbing motion.

10. Lightly brush the tongue after the teeth have been thoroughly cleaned.

11. Rinse the mouth vigorously with water.

12. If ordered, apply Glyoxide to the gums after each brushing.

NOTE: In order to effectively clean between the teeth, it is necessary to use dental floss in addition to the toothbrush. However, for the majority of handicapped and chronically ill, flossing will be extremely difficult or impossible. Those individuals who can floss or need to have their teeth flossed for them should be determined on an individual basis in consultation with a dentist or hygienist. Floss aids are available to living areas from the warehouse.

Toothbrushing Poster

The following page is available as an 11-inch by 17-inch poster by calling the Dental Clinic. The poster can be posted in bathrooms and training areas as an aid to proper toothbrushing for clients and staff.

SPECIAL ADAPTATIONS OF TOOTHBRUSHES FOR CLIENTS WITH UNUSUAL PROBLEMS

Many clients with chronic diseases and deformities have special problems in maintaining oral hygiene. Special adaptations of toothbrushes may be necessary to meet their needs. Inexpensive materials to make the special toothbrush adaptations can be obtained from a variety of sources. The following examples illustrate several toothbrush modifications:

Clients with Arthritis or Chronic Diseases of the Joints

A wide elastic band can be taped to toothbrush handle for persons who are unable to close their hands. Bands should be tight enough to hold brush snugly and avoid slipping.

Clients with Cerebral Palsy or Central Nervous System Disorders

Toothbrushes may be easier to control for these clients if they have an oversized handle made by building up with self-curing plastic from a hobby shop. A dentist can be helpful in recommending the proper plastic.

Another method for enlarging a toothbrush handle is:

1. Purchase bicycle handlebar grip (rubber or plastic) and small sack of quick setting plaster of Paris.

2. Mix small amount of very THICK plaster.

3. Fill bicycle grip with wet plaster. Cover hole in end of grip with adhesive tape to prevent plaster from running out the hole.

4. Push toothbrush handle into grip and hold until plaster hardens (few minutes).

5. Clean excess plaster off handle with damp cloth before plaster hardens.

This adaptation is also useful in enlarging the handles of spoons and forks.

A temporary method for enlarging a toothbrush handle is to push handle through middle of a soft rubber ball AFTER piercing ball with sharp object.Another temporary method is to glue a short piece of plastic tubing to the toothbrush handle.

Proper size handle can be determined by wrapping suitable material (aluminum foil, ace bandage, Styrofoam) around handle until comfortable size is reached.

Client with Limited Arm Movement

To make the handle longer cut the bristle portion off an old brush and attach this handle to handle of a new toothbrush. Secure with strong cord or plastic cement.

CLIENTS WHO ARE SEMI-COMATOSE

A coating may form on teeth (and on the gums of edentulous clients) even though the client is not taking food by mouth. The teeth and gums should be wiped 2 or 3 times a day with a piece of gauze or Toothette or cotton applicator moistened with water or Glyoxide. Mineral oil flavored with oil of lemon may also be used to moisten the gauze or applicator. It is very important to clean and lubricate the semi-comatose client's mouth to prevent the mouth tissues from drying. The client's lips may be lightly lubricated with Vaseline to prevent drying and cracking.

Additionally, for clients at risk of aspiration pneumonia, the attending physician may order oral care including the use of mouthwash swabs. (see below)

FOR CLIENTS WHO ARE AT RISK OF ASPIRATION PNEUMONIA

For clients who are identified by the unit physician as “at risk” of aspiration pneumonia, the teeth, gums and tongue should be swabbed with a Toothette® moistened with Listerine® after routine brushing. The Toothette should be damp, not saturated, and should be used to “paint” all the structures of the oral cavity. The Listerine will help reduce the bacterial colony count in the mouth. This procedure may also be beneficial for edentulous clients who are at risk for aspiration pneumonia. This protocol is used only on the order of a physician or dentist

MOUTHWASHES

Except for medicated mouthwashes prescribed by a physician or dentist for a specific disease, mouthwashes are solutions having pleasant tastes and odors. Mouthwashes may be useful in removing food particles loosened during toothbrushing, however, water is satisfactory for this purpose.

CARE OF TOOTHBRUSHES IN LIVING AREAS

1. Toothbrushes should be labeled with the client's name.

2. Toothbrushes will be replaced whenever they become worn or frayed.

3. After every brushing the toothbrush must be:

a. rinsed to remove all foreign matter

b. shaken to remove moisture

c. stored in a manner which permits drying between brushings.

4. Toothbrushes should be stored in a cabinet covered with screen wire. If a client has a contagious illness, consideration may be given to isolating the toothbrush from other clients' brushes.

5. Placement of toothbrushes in the storage cabinet should be staggered in order to prevent dripping on brushes below. (Note illustration at right)

6. If toothbrushes are stored in individual (personal) care kits, allowances must be made to insure each toothbrush will completely air dry between brushings.

DENTURES

All removable oral appliances (dentures and partials) must be labeled with the client’s name.

Oral hygiene practices do not stop with the loss of natural teeth. Cleanliness of dentures is important for the client's comfort and health. Dirty dentures can cause sore mouths and "denture breath". Food, stain, plaque, and calculus (tartar) collect on dentures (false teeth) the same as they do on natural teeth.

Dentures and removable partials should be brushed after each meal and rinsed in cold running water before being replaced in the mouth. The mouth, gums, and roof of the mouth should be brushed with a soft nylon toothbrush and rinsed with warm water before replacing the clean dentures.

It is recommended and especially desirable to remove the dentures each night to give a rest to the denture supporting tissue (gums). When the dentures are left out of the mouth for any length of time, they should be placed or stored in water. This practice will prevent drying and warping of the dentures.

Cleaning Dentures

1. Partially fill the washbowl (½ full) of water and hold denture near surface of water. The water will prevent denture from breaking if it is accidentally dropped.

2. Brush both inside and outside of denture.

3. Rinse with cold running water before replacing denture in clean mouth.

4. Metal clasps that fasten partial dentures to natural teeth need to be brushed well on inside of clasps to remove stains and food particles.

Denture Brushes

A stiff or hard bristle toothbrush, nail brush, or denture brush are satisfactory for cleaning dentures. Each client should have his own brush. Special clasp brushes for partial dentures are available to clean inside the metal clasps.

Stains and Odors

To remove stains and odors from dentures soak dentures overnight in glass of water with one teaspoon of laundry chlorine bleach (Clorox). However, partial dentures with metal frames or clasps should not be placed in this solution longer than 10 minutes. All partials and dentures should be thoroughly rinsed upon removal from this solution. DO NOT use pure bleach as pink base of denture may lose its color.

Hard Deposits

To remove hard deposits on denture, soak denture overnight in WHITE vinegar. (Brown vinegar may stain the pink base of the denture).

Denture cleaning aids are commonly available from drug, grocery, and variety stores. However, the American Dental Association does NOT recommend the use of liquid denture cleaners without the use of a brush. These solutions are only effective against loose debris, and denture cleanliness is dependent on regular daily immersion supplemented by brushing.

REFERRALS TO DENTAL CLINIC

In case of pain, discomfort, or any abnormal condition in the mouth, a dentist should be contacted as soon as possible. Although pain is NOT necessarily a criteria for early stages of dental disease, it may be present. Prolonged areas of irritation in the mouth may cause pre-malignant tumors or oral cancer. Ill-fitting dentures, clasps, or partial dentures, broken teeth, or oral habits such as cheek biting may contribute to irritation of mouth tissues. Any inflamed, swollen or ulcerated area in the mouth should be called to the attention of a dentist.

LIVING AREA PERSONNEL ESCORTING CLIENTS TO THE DENTAL CLINIC

If a client cannot come to the Dental Clinic alone and needs to be escorted by someone from a living area, the escort should remain with the client in the waiting room until a member of the dental staff asks for the client to come to a treatment room.

While the client is being treated, it is not necessary for an employee to remain in the waiting room but it may be practical to do so if the treatment is expected to be completed within a few minutes, i.e., examination. However, an escort from the living area should be available upon completion of treatment to escort the clients back to the living area.

If two or more clients from the same living area are appointed for the same time, such as may occur with examinations, only one escort needs to remain with all the clients until all are dismissed. The escort who remains in the waiting room may call the living area for additional assistance, if so desired, to escort the clients back to the living area after completion of treatment.

If a client comes to the Dental Clinic with an injury, such as may occur as a consequence of a fall, that client will be treated before seeing regularly scheduled clients. An extenuating circumstance such as this or earlier scheduled clients arriving late, etc., may cause the staff to get behind schedule. The appointment clerk usually calls the living areas if appointments get significantly off schedule.

In summary, it is expected the living areas will provide an employee to escort clients to the Dental Clinic as needed and to escort them from the Dental Clinic back to the living area upon completion of treatment.

Material on oral hygiene obtained from "A Manual of Oral Hygiene for Handicapped and Chronically Ill Patients", distributed by the Department of Human Resources, and "Clinical Practices of the Dental Hygienist", 4th Edition, 1976, Lea and Febiger, by Ester M. Wilkins, B.S., R.D.H., D.M.D.