Instructions for healthcare staff

Oral care for people with special needs

Dental health forms dental calculus (tartar). Tartar contains germs which can cause
irritation in the gums.
Clean and healthy teeth are important for our wellbeing.
Dental health is primarily a matter of good dental It is important to allow plenty of time (2-3
hygiene, healthy eating and drinking habits, use of minutes) for brushing. Start, for instance, on the
fluoride, and regular dental check-ups. In modern insides of the teeth, on the left. The brush hairs
society it is entirely possible for people to keep their should be placed obliquely to the gums. Press
own teeth throughout their lives. on the brush, with the hairs between the teeth and
the gum line, and rub away from the gums. Brush
Teeth vary in size and shape: incisors, canines, back and forth with short strokes. Then brush the
premolars and molars. A tooth comprises two parts: biting surface of the molars, making sure to brush
crown and root. The crown is the visible part of the fissures thoroughly to remove plaque. Continue
the tooth, which projects into the oral cavity, while to the outer surface of the molars, and remember to
the root is the hidden part, which is rooted in the brush thoroughly behind the back tooth. Brush the
jawbone. The crown is surfaced in enamel, beneath canine and incisor areas thoroughly. When the back
which is dentine. The reddish area in the middle of the incisors is brushed, the brush must be held
is known as pulp. Around the root is connective tissue vertically and moved up and down. Then continue
which attaches the tooth to the jawbone. The gums are with the other three sectors of the mouth.
pale pink in colour, and are tightly moulded to the teeth.
Use of a soft, dense brush and fluoride toothpaste
is recommended. Do not rinse the mouth after
Dental hygiene brushing. The fluoride in the toothpaste will
remain active for longer if the mouth is not rinsed.
Hygiene is necessary to every person, and clean teeth are no exception. Swallowing a little toothpaste does no harm.
The mouth contains bacteria which can damage teeth and gums. Certain
bacteria attach themselves to the teeth to form plaque, a whitish film which Electric toothbrushes are useful for dental care, but
adheres to the surface of the enamel. The more frequently sugary foods must be used correctly. The brush is placed against
are eaten, the faster the plaque will form. Plaque the tooth surface, and kept in the same place for
must be removed regularly, in order to prevent about three seconds, following the curve of the tooth
oral ailments such as dental decay and gingivitis surface. Then the brush is moved to the next tooth,
(inflammation of the gums). Plaque which is left and each tooth surface brushed: outside, inside and
on the teeth for a long time absorbs minerals and chewing surfaces.
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Floss should be used to clean between the teeth at Fluoride chewing gum can be useful for people whose saliva production
least once a day. Cut a length of floss long enough is limited, and also for anyone whose risk of dental decay is increased for
to wind around the fingers, then carefully insert any reason. Some diseases and medications, as well as dry mouth and poor
it between the teeth and down to the gap between diet, lead to increased risk of dental decay, and in such cases it is advisable
teeth and gum. Pass the taut floss up and down on to increase fluoride use, for instance by rinsing the mouth regularly with a
each side. The floss must be held firmly against fluoride mouthwash.
the tooth surface throughout. Floss all the gaps
between the teeth in the upper and lower jaw. If the Eating and drinking habits
gums bleed, this is a sign of inflammation of the
gums, indicating that even better dental hygiene is Healthy eating and drinking habits are
required. the basis of good dental health. Bacteria
which adhere to the surface of teeth
Interdental brushes can be used to clean larger transform sugars from food into acids,
gaps between teeth and gums. They are also useful which release minerals from the teeth for
or cleaning around bridges and implants. Insert the interdental brush about half an hour after sugary food is
carefully, and brush back and forth against the tooth surface 5-8 times. eaten. A person who is always nibbling at
sweet foods and drinking acid drinks will
always be in the “red” or “pink” sector of
Fluoride the scale (upper Food Clock, see right),
Use of fluoride is recommended to prevent dental decay. Fluoride is the with an increased risk of dental decay and
most important ingredient of toothpaste, and it erosion of enamel.
affects the chemical processes which are constantly
taking place in the dental surface. If there is Saliva plays a key role in the body’s
sufficient fluoride in the mouth, it can contribute to defences against dental disease. If the
recalcification, and can reverse early-stage dental interval between meals is normal, the body’s defences can successfully
decay. resist acids and dental decay, and enamel erosion is controlled (lower
Food Clock, right).
Toothpaste should be applied to cover about one-
third of the head of the toothbrush. The frequency A piece of cheese after a meal protects the teeth, and the same is true of
and duration of fluoride being in contact with the sugar-free gum. Constant snacking is too much for the defensive system to
teeth is important, so leave the toothpaste in the cope with.
mouth. Do not rinse after brushing. Simply spit out
the excess.

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Saliva
Adequate saliva production is vital to well- ing the surface of the teeth, leading to tooth decay. Bacteria in the plaque
being, and maintains oral health through a convert sugars from food into acids, which dissolve the surface of tooth
neutral pH level (neither acid nor alkaline). enamel, and minerals leach out.
The saliva flows from salivary glands which
are located in the floor of the mouth and in the The dark spot visible here is dental decay at an
cheeks. Dry mouth can be a side-effect of cer- early stage. Acids have dissolved the dental surface.
tain diseases and medications; the symptoms While the decay is confined to the enamel, it can be
are soreness of the mouth, and difficulty in stopped or reversed by improved dental hygiene,
speaking, chewing and swallowing. Persistent dryness of the mouth leads additional fluoride treatment and better eating and
more, and faster, tooth decay. The incidence of problems with oral mucous drinking habits.
membranes and gums also increases. Problems also often arise with use
of dentures. Good dental hygiene is always important, and even more so Enamel dissolves rather slowly, but when the decay
where the mouth is dry. has eaten through the enamel to the dentine the de-
cay progresses more rapidly. At this stage a dentist
Dental check-ups must remove the decayed tissue and fill the tooth.
When tooth decay approaches the pulp and the
Regular dental check-ups are a vital aspect of dental care and treatment. tooth becomes infected, inflammation results, which
The frequency of check-ups varies from person to person, in accord leads to pressure and toothache.
with their risk level, but visiting the dentist at least once a year is recom-
mended.

Root damage
Dental diseases
Root damage is a growing problem among the
Dental caries/decay elderly. The gums may shrink, leaving part of the
root exposed, and unprotected by the mucous mem-
Certain types of bacteria adhere to the surface of brane; this becomes an ideal site for plaque. The
the teeth and form a film (plaque), which must be unprotected root is highly susceptible to decay, and
removed by regular brushing at least twice daily. additional fluoride treatment is absolutely necessary
If a person is constantly snacking, so that the sugar in order to hinder decay of the dental root.
level in the mouth is high, plaque forms more rapid-
ly. If dental hygiene is poor and plaque builds up, it prevents saliva reach-

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Gingivitis reabsorbed if the environment of the mouth remains acid. If an acid drink
is drunk every 10 to 15 minutes, for instance, the saliva can never reduce
The teeth are rooted in the jawbone, where they are fixed by narrow the pH level of the mouth to a neutral level. The enamel grows thinner,
threads of connective tissue. Healthy gums tightly surround the tooth like and the teeth become more sensitive to heat and cold. It is advisable to
a snug collar, and are pale pink in colour. Gingivitis (inflammation of the limit consumption of acidic drinks to certain times of the day, or of the
gums) is caused by the body’s immune reaction to week, in order to prevent enamel erosion. Water is the best drink!
the bacteria in plaque on the dental surface. The
bacteria are thus an irritant, without entering the
connective tissue itself. The gums become red
and swollen, and bleed easily. The inflammation
disappears if oral hygiene is improved.

Persistent gingivitis often leads to more serious

periodontal (gum) diseases. The inflamed gum
tissue can become separated from the tooth, and the
inflammation spreads to the periodontal fibres.
This leads to damage to the periodontal fibres
and the jawbone, and the teeth gradually Dental hygiene for those who have their own
loosen. Smoking triples the risk of periodontal natural teeth
inflammation, although the symptoms are generally less severe. Gingivitis
often causes little or no discomfort, and thus diagnosis is often delayed. It
is vital to prevent the problem through good oral hygiene, before it takes Dental hygiene for patients
hold. Long-term illness increases the likelihood of dental health problems.
Handicapped, ill and elderly people require help from healthcare staff
Enamel erosion with their dental hygiene. Good dental hygiene is essential if natural teeth,
implants and bridges are to continue to serve their purpose in the long
When the environment of the mouth is in
term. In healthcare facilities, nursing homes and in home nursing, dental
equilibrium, the flow of minerals out of the surface
hygiene must be part of the routine of daily care. It is important to provide
of the teeth and into it is equal. Saliva maintains the
appropriate assistance as required by each individual.
correct pH balance, but if a person drinks an acid
drink the acidity rises, and minerals leach out of the teeth. Enamel erosion
In dental care of very ill patients it is important to explain what is
takes place when acids eat away at the surface of the tooth, eroding the
happening, raise the head, and spread a towel over neck and chest. Hands
enamel. Acids remove minerals from the enamel, and they cannot be
must be washed, and gloves used.

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Start by applying Vaseline to the lips, and open Many people have a removable partial
the mouth by gently grasping the patient’s denture. This is removed before brushing the
chin. A swab can be used to open the mouth. natural teeth. The teeth are brushed on all sides
It is advisable to use a bite block between the using a soft brush and fluoride toothpaste, and
molars to keep the mouth open, and it is a occasionally with chlorhexidine. Do not be put
good idea to fix dental floss to the block. off by a little bleeding from the gums, simply
brush better. Encourage the patient to rinse the
mouth with lukewarm water. Finally, apply
The upper and lower teeth on the right are a little fluoride toothpaste to the surface of the teeth. The denture is also
then brushed with a low-foam toothpaste thoroughly cleaned.
with high fluoride content, and occasionally
with chorhexidine. When the bite block is If the patient is on medication, ensure that it is swallowed at once. Tablets
transferred to the other side of the mouth the which are held in the mouth for a long time can damage the mucous
swab can be used to open the mouth a little membrane. No medications containing sugar or syrup should be used –
more. Clean the surfaces between the teeth only sugar-free versions should be used.
with floss.
Those who are not fed by mouth still form plaque on their teeth and
tongue, which must be removed by good dental hygiene at least once a
day. It is also advisable to moisten the gums, tongue, mucous membrane
If the patient has bridges, implants or and lips every 4-5 hours with water or artificial saliva.
overdentures use interdental brushes with
chorhexidine. Use only a small quantity of
chlorhexidine, as there is a risk of it entering
Dental hygiene for handicapped people
the respiratory tract of very ill individuals.
Floss with a stiffened end can also be used, Dental hygiene must be a part of the daily routine of handicapped people.
and passed along the teeth and gums. Finally It is important to provide the appropriate assistance required by each
wipe the mucous membranes with damp gauze individual. While most handicapped children’s teeth are initially as healthy
or an oral swab, and apply Vaseline to the lips. as those of other children, they are far more likely to have oral problems.
Some bite or gag when their teeth are brushed, or refuse to allow anyone
A bite block can be improvised from 4-5 tongue depressors, taped together to touch their mouth. Medication can led to severe dryness of mouth, and
and wrapped in gauze. certain medications cause gingivitis. Handicapped people with limited
motor control require full assistance in dental hygiene.

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Give yourself plenty of time. Explain what All individuals are encouraged to participate in their own dental hygiene
is happening, and follow the individual as far as possible, but many handicapped people require full assistance
instructions, for instance on the oral care with cleaning their teeth at least once a day. Some handicapped people
information form. Find out how far the person are largely able to manage their own dental hygiene, but they require
can tolerate being touched in the mouth area, supervision. Dental care equipment must be renewed regularly. Healthcare
and gradually increase this tolerance. staff is responsible for providing expert assistance where teeth or dental
prosthetics are hard to clean.
Always use gloves. It is advisable to use a
finger guard or bite block to keep the mouth
open. The lips and cheeks must be lifted
to give a clear view. The teeth are brushed
Dental hygiene for those with removable
with a manual or electric toothbrush and dentures
fluoride toothpaste. The spaces between teeth
are flossed. Chlorhexidine should be used
occasionally. Partial dentures
Keeping one’s natural teeth is ideal, but if one
Electric toothbrushes are highly suitable for or more teeth are missing there are various
brushing the teeth of handicapped people. It options: implants, fixed bridges, or removable
is a good idea to wipe the tongue and mucous partial or complete dentures can be fitted. In
membranes with damp gauze after brushing, some cases implants can be embedded in the
and apply cream to the lips and cheeks. jawbone, so that dentures can be fixed more
securely.
It is important to find the best posture for
cleaning another person’s teeth. For a person If only a few natural teeth remain in the
in a wheelchair, it can be convenient to stand mouth, they must be kept clean, and mucous
behind the chair. Brushing while the person is membranes must be kept in good condition,
lying down may also be a good solution. The so that the denture continues to be usable. The
handicapped person should be familiarised denture is removed from the mouth, taking
with his/her own dental hygiene equipment, care not to bend the metal parts. Carefully insert a fingernail under the
and dental care should take place in a familiar retainer on each side and press slightly to detach the denture. The teeth
place where stress is minimised. are brushed on all sides with fluoride toothpaste, and occasionally with
chlorhexidine. Clean the oral cavity thoroughly with a damp sponge or
gauze. Do not forget to clean the tongue.

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When cleaning the denture, it is advisable to shortage. In such a case a dentist or doctor
have a bowl of water in the sink beneath it, to should be consulted. The oral cavity is cleaned
avoid breakage if the denture is dropped. Use thoroughly with a moist sponge or gauze, and
a special toothbrush for cleaning the denture, the lips are wiped. Do not forget the tongue,
and clean it thoroughly all over, inside and which should be wiped 2-3 times.
out. Brush the nooks and crannies well with
the narrow end of the brush. Use a mild liquid When cleaning dentures, it is advisable to have
soap, or a specialised cleaning agent for the a bowl of water in the sink beneath it, to avoid
purpose, available at pharmacies. Never use toothpaste, as it contains breakage if the denture is dropped.
abrasives which could scratch the plastic parts of the denture. Finally rinse
the denture thoroughly in cold water and leave overnight in cold water, or The photo shows how to hold a denture for
return to the mouth. cleaning. Clean it thoroughly all over, inside
and out, with a special toothbrush and a mild
Complete dentures liquid soap, or a specialised cleaning agent
for the purpose, available at pharmacies.
If there are no natural teeth in the mouth, the dentures must be kept clean, Never use tooth-paste, as it contains abrasives
and the mucous membrane beneath must be kept healthy. which could scratch the plastic parts of the
denture. Finally rinse the dentures thoroughly
Here an upper denture is removed from the in cold water and return to the mouth, or leave
mouth. If the denture is very firmly fixed, overnight in water. Complete dentures must always be kept in water. If
insert the index finger gently between the they dry out, they may become warped. When the dentures are replaced in
denture and the cheek, and press the denture the mouth, make sure that the lips are not caught and pinched.
downwards. Remove the lower denture in the
same way.
Useful tips:
When the dentures have been removed, it • It is recommended that dentures be sterilised at least once a month by soaking
is a good idea to examine the oral cavity overnight in a 0.2% solution of chlorhexidine (1 cup of water/10 ml of
thoroughly. Look for reddening or sores which chlorhexidine).
may form when the gums shrink and the • Tartar (calculus) can be removed by soaking the denture overnight in a vinegar
dentures no longer fit properly. This individual solution (1 cup of water/1 teaspoon of vinegar) when necessary.
has sores in the corners of the mouth, which • Staining by coffee/tea can be reduced by soaking the denture in a solution of baking
may be due to ill fitting dentures, bacterial soda (sodium bicarbonate) - one cup water/1 teaspoon baking soda - for about ten
infection, a fungal infection or vitamin minutes when required.
November 2012, Hólmfríður Guðmundsdóttir, dentist
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