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  • 1. EAST CENTRAL REGIONAL HOSPITAL DENTAL DEPARTMENT LIVING AREA ORAL HEALTH CARE TABLE OF CONTENTSINTRODUCTION............................................................................................................................ 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 - i 6/2004
  • 2. INTRODUCTIONThe handicapped and mentally retarded client frequently has complex dental problems such assore 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 theiroral hygiene. Crippling and immobilizing effects of disease often make normal procedures fororal hygiene difficult or impossible. Health service personnel can help these clients with avariety 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 togetherin establishing and maintaining the cleanliness of the mouth.TOOTHBRUSHINGThe type of toothbrush is extremely vital to proper oral hygiene. The toothbrush recommendedby 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).
  • 3. 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 PosterThe following page is available as an 11-inch by 17-inch poster by calling the Dental Clinic. Theposter can be posted in bathrooms and training areas as an aid to proper toothbrushing forclients and staff.
  • 4. SPECIAL ADAPTATIONS OF TOOTHBRUSHES FOR CLIENTS WITH UNUSUALPROBLEMSMany clients with chronic diseases and deformities have special problems in maintaining oralhygiene. Special adaptations of toothbrushes may be necessary to meet their needs.Inexpensive materials to make the special toothbrush adaptations can be obtained from avariety of sources. The following examples illustrate several toothbrush modifications:Clients with Arthritis or Chronic Diseases of the JointsA wide elastic band can be taped to toothbrush handle for persons who are unable to close theirhands. Bands should be tight enough to hold brush snugly and avoid slipping.Clients with Cerebral Palsy or Central Nervous System DisordersToothbrushes may be easier to control for these clients if they have an oversized handle madeby building up with self-curing plastic from a hobby shop. A dentist can be helpful inrecommending 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 asoft rubber ball AFTER piercing ball with sharp object.
  • 5. 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, acebandage, Styrofoam) around handle until comfortable size is reached.Client with Limited Arm MovementTo make the handle longer cut the bristle portion off an old brush and attach this handle tohandle of a new toothbrush. Secure with strong cord or plastic cement.CLIENTS WHO ARE SEMI-COMATOSEA coating may form on teeth (and on the gums of edentulous clients) even though the client isnot taking food by mouth. The teeth and gums should be wiped 2 or 3 times a day with a pieceof gauze or Toothette® or cotton applicator moistened with water or Glyoxide. Mineral oilflavored with oil of lemon may also be used to moisten the gauze or applicator. It is veryimportant to clean and lubricate the semi-comatose clients mouth to prevent the mouth tissuesfrom drying. The clients lips may be lightly lubricated with Vaseline to prevent drying andcracking.Additionally, for clients at risk of aspiration pneumonia, the attending physician may order oralcare including the use of mouthwash swabs. (see below)
  • 6. FOR CLIENTS WHO ARE AT RISK OF ASPIRATION PNEUMONIAFor clients who are identified by the unit physician as “at risk” of aspiration pneumonia, theteeth, gums and tongue should be swabbed with a Toothette® moistened with Listerine® afterroutine 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 inthe mouth. This procedure may also be beneficial for edentulous clients who are at risk foraspiration pneumonia. This protocol is used only on the order of a physician or dentistMOUTHWASHESExcept 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 inremoving food particles loosened during toothbrushing, however, water is satisfactory for thispurpose.CARE OF TOOTHBRUSHES IN LIVING AREAS1. Toothbrushes should be labeled with the clients 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.DENTURESAll 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 isimportant for the clients comfort and health. Dirty dentures can cause sore mouths and
  • 7. "denture breath". Food, stain, plaque, and calculus (tartar) collect on dentures (false teeth) thesame as they do on natural teeth.Dentures and removable partials should be brushed after each meal and rinsed in cold runningwater before being replaced in the mouth. The mouth, gums, and roof of the mouth should bebrushed with a soft nylon toothbrush and rinsed with warm water before replacing the cleandentures.It is recommended and especially desirable to remove the dentures each night to give a rest tothe denture supporting tissue (gums). When the dentures are left out of the mouth for anylength of time, they should be placed or stored in water. This practice will prevent drying andwarping of the dentures.Cleaning Dentures1. 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 BrushesA stiff or hard bristle toothbrush, nail brush, or denture brush are satisfactory for cleaningdentures. Each client should have his own brush. Special clasp brushes for partial denturesare available to clean inside the metal clasps.Stains and OdorsTo remove stains and odors from dentures soak dentures overnight in glass of water with oneteaspoon of laundry chlorine bleach (Clorox). However, partial dentures with metal frames orclasps should not be placed in this solution longer than 10 minutes. All partials and denturesshould be thoroughly rinsed upon removal from this solution. DO NOT use pure bleach as pinkbase of denture may lose its color.Hard DepositsTo remove hard deposits on denture, soak denture overnight in WHITE vinegar. (Brown vinegarmay 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 cleanerswithout the use of a brush. These solutions are only effective against loose debris, and denturecleanliness is dependent on regular daily immersion supplemented by brushing.
  • 8. REFERRALS TO DENTAL CLINICIn case of pain, discomfort, or any abnormal condition in the mouth, a dentist should becontacted as soon as possible. Although pain is NOT necessarily a criteria for early stages ofdental 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, ororal 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 CLINICIf a client cannot come to the Dental Clinic alone and needs to be escorted by someone from aliving area, the escort should remain with the client in the waiting room until a member of thedental 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 waitingroom but it may be practical to do so if the treatment is expected to be completed within a fewminutes, i.e., examination. However, an escort from the living area should be available uponcompletion 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 mayoccur with examinations, only one escort needs to remain with all the clients until all aredismissed. The escort who remains in the waiting room may call the living area for additionalassistance, if so desired, to escort the clients back to the living area after completion oftreatment.If a client comes to the Dental Clinic with an injury, such as may occur as a consequence of afall, that client will be treated before seeing regularly scheduled clients. An extenuatingcircumstance such as this or earlier scheduled clients arriving late, etc., may cause the staff toget behind schedule. The appointment clerk usually calls the living areas if appointments getsignificantly off schedule.In summary, it is expected the living areas will provide an employee to escort clients to theDental Clinic as needed and to escort them from the Dental Clinic back to the living area uponcompletion of treatment.Material on oral hygiene obtained from "A Manual of Oral Hygiene for Handicapped andChronically Ill Patients", distributed by the Department of Human Resources, and "ClinicalPractices of the Dental Hygienist", 4th Edition, 1976, Lea and Febiger, by Ester M. Wilkins, B.S.,R.D.H., D.M.D.