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Helping the special needs patient maintain oral health: how to design a special needs daily preventive oral health care program.

Poor oral hygiene and dental disease may be more prevalent in patients with disabilities due to the effects of theft condition and medication on the oral environment. Malocclusion and/or teeth with developmental defects, oral habits such as pouching of food, and even poor physical coordination contributes to poor oral hygiene. Some patients cannot grasp a toothbrush or reach theft mouth; their lack of ability for self-care may have serious health implications. Assessment and education skills are essential to develop a home care routine that patients and/or caregivers can follow to help prevent disease and maintain oral health. A daily preventive program must be effective, simple to use and low in cost. (1) As discussed in previous articles, the main objectives of care are:

* Motivate patients and caregivers to maintain oral health.

* Prevent infection and tooth loss.

* Prevent the need for extensive treatment that patients may not be able to tolerate due to their physical or mental condition. (2)

After reading this article, the reader should be able to:

* Assess patients' needs based on oral conditions and abilities.

* Develop home care techniques and modifications that will best fit patients' abilities.

* Provide instruction for oral self-care to patients with physical or mild to moderate mental disabilities.

* Provide education and oral care instruction to caregivers of dependent patients.

* Incorporate the use of sealants, antimicrobial agents, fluoride, and diet counseling as part of a total prevention program.

* Encourage regular dental visits to evaluate effectiveness of the program.

PATIENT ASSESSMENT

Before any prevention program can be developed, the dental team must determine patients' needs based on their oral condition and ability. A dental exam is essential to determine if treatment is necessary. Once treatment is completed, disease prevention and control is the key. "The components of an effective program are the same for all persons regardless of disability, but their delivery and application must be altered to meet the needs of those who are disabled" (1) An ideal prevention program, which may involve a parent or caregiver, should include education, plaque biofilm control, chemical agents such as antimicrobials and home fluorides and diet counseling. Sealants should be considered for caries control and can only be professionally applied in the dental office. Regular dental visits should be part of the plan to evaluate effectiveness of the program and make modifications when necessary. (1,2,4)

Assessment and skill evaluation can help determine ff patients can do what you want them to do. Box 1 (right) outlines considerations for effective program planning. Can patients brush and floss on their own or are they partially or totally dependent on a caregiver? It is vital to observe the current technique. How does a patient's disability affect self-care and what modifications will be necessary to enable a patient to be as independent as possible? (See Table 1 Skill Level on page 34.) When designing any device for self-care it is important to judge how the patient's physical and mental limitations will affect its use.
Box 1

Planning Considerations (2)

1. What is the patient's skill level--High, Moderate,
or Low? (see Table I on page 34.)

2. How do patients' disabilities affect their self-care
efforts (disability- mental, physical or
sensory)?

3. What is the dental health of the caregiver and
how does he or she feel about dentistry?

4. What techniques will best fit patients and/or
caregivers?

5. What modifications will be necessary to help patients
function as independently as possible?


SKILL EVALUATION AND DESIGN OF SELF-CARE DEVICES (1-5)

Range of Motion

Obstacle--Inability to reach the mouth with arms and hands.

Evaluation Technique--Judge the patient's ability to extend his or her arms and reach the mouth. Patients with muscular impairment may be able to bend their arms halfway across the body but only elevate their arms to the level of the heart. The range of motion will determine the needed length of the device.

Solution--Extended handle made from plastic rulers or rods available at most hardware stores or a wooden spoon. Attach to the toothbrush and floss holder with heavy electrical tape.

Obstacle--Unable to bend at the elbow or wrist.

Evaluation Technique--Have the patient try to reach certain areas of the mouth by bending the arm and wrist (posterior of the maxillary buccal and mandibular lingual maybe the most difficult areas for the person to reach).

Solution--Use a compact head toothbrush for better intraoral fit, angle the toothbrush handle by gently heating above a flame or hold the handle under very hot water until it becomes pliable. A commercially available toothbrush, such as the Surround[R] Toothbrush with two opposing brush heads shown in Figure 1 (right) is designed to clean the buccal, occlusal and lingual tooth surfaces at the same time. The handle is extra long and curved to permit an easy, controlled grip.

Grip Strength

Obstacle--Difficulty holding a device that is too narrow or small.

Evaluation Technique--Have the patient grasp various size balls (tennis ball, soft ball and golf ball are useful) to determine extent of finger closure around the ball. To determine a patient's strength and how long he or she can grasp a device, hold the patient's hand gently and ask him or her to squeeze with as much force as possible for one minute. Patients with arthritis or neuromuscular disorders may have difficulty.

[FIGURE 1 OMITTED]

Solution--Figure 2 (right) illustrates materials that will provide bulk to assist with grip. Bicycle grips, balls and Styrofoam molds come in several sizes, weights and textures and can be found in most hardware and craft stores. Silicone putty molded with the patient's hand around a toothbrush handle will provide a custom alternative. These materials are ideal because they are inexpensive and can easily be cleaned or replaced. For patients who cannot hold a device on their own, a universal strap made with a Velcro strip can be attached to their hands. To help get toothpaste out of the tube you can enlarge the cap with acrylic, use a tube squeezer or consider a pump action toothpaste dispenser or a tube with a snap cap.

Design Characteristics for Self-Care Devices

* Use of a soft bristle, rounded, nylon toothbrush is the best choice.

* The size of the brush is determined by the size of the mouth and the patient's ability to open.

* Device should not cause damage to the teeth and/or gingival tissues.

* Material should be readily available, lightweight and inexpensive.

* Device should be easily constructed with replaceable parts (parts that become worn out or dirty should be easily replaced).

* Device should be easy to use and have minimal set-up time.

Automatic Devices

* Consider an automatic toothbrush and flossing device such as Oral B[R] Hummingbird

* Before recommending any automatic devices, observe patients to see if they have the strength to hold it. Instruct caregivers on proper use.

* Patients with disabilities such as autism or Alzheimer's disease may not tolerate the noise and vibration of such devices.

[FIGURE 2 OMITTED]

Dental professionals realize how difficult it is to change behavior to maintain oral health. Change is effected through education as a major part of any oral hygiene program, whether it is directed at the disabled patient or the caregiver or both. It's important that the person you are teaching understands the reasons for good oral health, why any change in behavior is necessary and the consequences of continuing poor oral hygiene conditions. Observe the patient's or caregiver's technique directly and if needed make the changes in small increments. If possible, work within what is already being done. (6)

INSTRUCTION FOR THE PATIENT (2, 4, 5)

Patients should be encouraged to do as much on their own as they are able. This reduces dependency on others and may result in feelings of higher self-esteem and accomplishment. Determine patients' abilities to understand and follow directions by asking questions during skill evaluation. Do they respond appropriately to your verbal commands and instruction? Those with mild or moderate mental disability will be able to manage most toothbrushing methods such as scrub brush, sulcular, rolling and circular methods.

Learning tools can include use of pictures and/or modeling of others. The tell-show-do method of teaching may be effective. Each step of the procedure is explained and shown to the patient and then the patient demonstrates the activity. Disclosing tablets or solutions are helpful to see areas of plaque biofilm. To encourage brushing for an adequate length of time, use an egg timer and increase the amount of time slowly starting with 30 seconds, then 60, then 90 and finally 120 seconds. Daily supervision and motivation are necessary. The patient with more serious mental or physical impairment may not be able to per form successfully on their own. If they are dependent on someone else, then it is best if both patients and caregivers understand the causes and techniques for prevention of dental disease.

INSTRUCTION FOR THE CAREGIVER (1, 3, 4, 5)

Plaque biofilm formation and disease development should be explained to the caregiver. Learning the signs of oral health and disease states is necessary Raise the dental awareness of caregivers and motivate them to take good care of their own mouths in order to provide better care to their patients' mouths. Positioning and restraint techniques used by a caregiver for providing daily oral health care must include the following:

* Review of state legal considerations for informed consent be fore using any type of restraint.

* Explain procedure to the patient.

* Head stabilization is necessary to allow for proper brushing and to prevent injury:

* Access to the mouth with lip and cheek retraction will allow for proper toothbrush placement.

* Visibility to confirm toothbrush placement and effective plaque biofilm removal is needed.

LOCATION AND POSITIONING FOR ORAL CARE

Depending on the patient's general health status, determine what location will work best for oral care. A sink may not be necessary; the patient can expectorate into a cup or caregiver can work with a bulb syringe, basin, cup and towel. If the patient is in a wheelchair this may be the best place to provide care. The patient can sit on the floor or in a straight-back chair. Reclining on the couch, bed or in a beanbag chair may work for patients who have difficulty sitting up straight. This seating method lets them relax without the fear of falling.

Whatever area is chosen caregivers need to adjust their positions as necessary. If the patient is in a chair, wheelchair, sitting on the floor, or using a bean bag chair, the caregiver should be positioned behind the patient. Figure 3 and Figure 4 (page 36) illustrate these positions. If the patient is lying on a couch, a pillow should be placed on the caregiver's lap for the patient's head to rest on. If the patient is in a bed, the caregiver should stand beside the bed. Turn the patient's head to the side and place a towel under his or her chin. Have a basin ready for rinsing options. Before any care is attempted first approach the patient from the front to explain the procedure.

PROCEDURE

Head stabilization can be accomplished with the use of pillows or a chair or couch with a high back. When standing behind patients, caregivers can wrap a free arm around the patient's head and cradle the chin by hand. The mouth can be viewed from above. Apply gentle downward pressure to the chin with the index, middle, ring and pinky finger placed on the mandible. Place the thumb in the vestibule to retract the lip. Do not try to stop all patient movement; it is better to go with the movement. An increase in pressure can agitate and increase movement. Stop frequently to allow the patient to take deep breaths and relax.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

Tongue movements can interfere with reaching the lingual surfaces. Allow patients to keep their teeth together until lingual access is necessary. This reduces stress for the patient and may provide better visualization. A mouth prop made of a soft rolled face cloth or gauze may be used to help patients keep theft mouths open. Never place fingers between the maxillary and mandibular teeth; caregivers should watch their patients' mouths whenever caregivers' fingers are in or near the mouth.

Control of the patient's hands is essential. If necessary, a partner can gently hold the patient's hands while care is provided. If more restraint is needed, cross the patient's arms and bring together in the center of his or her body. Avoid holding the patient at the joints; it is safer to secure the patient's arms by holding at points between joints. Talk slowly and softly in a monotone to control and calm the patient. Holding a patient's head or hands is considered a form of restraint. Remember, it is important to check with state legal considerations for informed consent before using any type of restraint.

ADDITIONAL CONSIDERATIONS

When providing care the caregiver needs to wear proper Personal Protective Equipment that includes a disposable gown, gloves, face shield or safety glasses and a mask. A flashlight or goose neck lamp will provide better visibility. Protect the patient's airway and avoid aspiration of water or toothpaste. Use very small amounts of water. Use toothpaste only for patients who can spit. Emphasize that it is the action of the brush that removes plaque biofilm not paste. Foam from toothpaste is difficult to remove, can interfere with visibility, and might be aspirated. Consider the use of nonfoaming, ingestible toothpaste. For patients at risk for aspiration of fluids, toothbrushes with suctioning devices such as the Plak-Vac[R] (Trademark Medical Corporation) are available. (7) Encourage the use of disclosing agents to visualize plaque biofilm. Caregivers who are able to floss the teeth should always use floss holders to keep their fingers from between arches and avoid being bitten.

FLUORIDE, ANTIMICROBIALS AND DIET COUNSELING (2, 4)

Fluoride should be considered to control caries. The person's need and disability will determine how it's used. A mouth rinse before bedtime can be used by the patient who is mentally competent and is able to spit out. A chewable tablet is a good choice for the patient who can chew and needs a supplement. Alternatives are fluoride varnish, a swab or a daily brush on gel. (2) Brushing with a fluoride gel instead of toothpaste may be more appropriate for patients dependent on caregivers.

The use of antimicrobial agents such as chlorhexidine has been proven effective in reducing the severity of plaque accumulation and gingivitis. For those who cannot swish and rinse, alternative methods for application are a spray; swab or toothbrush. Chlorhexidine does cause staining and possible taste alteration. Listerine[R] and similar mouthwashes have proven effective against plaque biofilm, are cheaper to use and do not cause the problems associated with chlorhexidine. Any antimicrobial agent should be prescribed for only a specific length of time and be monitored for effectiveness. (4)

Diet instruction is another important part of a total preventive program. Eating habits, cultural beliefs, customs and financial resources are factors that should be evaluated before recommendations can be made. The inability to chew may lead to the choice of a soft carbohydrate-rich diet. Sweets used as rewards should be discouraged. Many medications contain sugar, therefore rinsing with water after dosage should be encouraged. All of these issues place the patient at risk for caries. (2)

CONCLUSION

For the patient with a disability there are many factors that can contribute to poor oral health. Once any treatment is completed it is essential for the dental professional to be able to develop a total daily prevention program for that patient based on need and ability. Devices to aid in overcoming obstacles to oral hygiene are available commercially. Using your imagination can often provide an effective alternative to help the patient and/or a caregiver achieve oral health. If a caregiver is involved, both the patient and caregiver should be educated in all aspects of an oral health care program. The next article will provide your office with the tools to successfully treat the patient with a sensory disability.

REFERENCES

(1.) DECOD Program (Dental Education in Care of the Disabled). Module III. Dental prevention for the patient with a disability (a series of 12 booklets). 2nd ed. Seattle: DECOD, School of Dentistry; University of Washington; 1998.

(2.) Wilkins, E.M. Care of patients with disabilities. In: Clinical Practice of the Dental Hygienist. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2009:870-98

(3.) Eshenaur Spolarich, A. Persons with disabilities. In: Darby and Walsh. Dental Hygiene Theory and Practice. 2nd ed. St. Louis, Mo.: Saunders; 2003: 764-81.

(4.) Southern Association of Institutional Dentists. Preventive Dentistry for Persons with Severe Disabilities. Module 11. Self Study Course (a series of 1S Modules) available at: http://saiddent. org/modules.asp. Accessed October 10, 2008.

(5.) Dougal, A., Fiske, J. Access to special care dentistry; part 4. Education. Br Dent J. 2008; 205:119-30.

(6.) Christensen, G., J., Special oral hygiene and preventive care for special needs. J Am Dent Assoc. 2005; 136 (8): 1141-43.

(7.) Stiefel, D., J., Truelove, E., Role of rehabilitation dentistry--good oral health and hygiene for people with disability contributes to rehabilitation. Am Rehabilitation. 1990 autumn. Available at: http://findartides.com/p/articles/mi m0842/is n3 v16/ ai_1008729/?tag=content;col1. Accessed October 10, 2008.

(8.) Stiefel, D., J., Dental care considerations for disabled adults. Spec Care Dentist 22(3)26S-39S, 2002.

REFERENCES FOR PHOTOGRAPHS AND FIGURES

Figure 1--Specialized Care Company; Edison NJ. Available at: http://www. specializedcare.com.

Figure 2--Reprinted with permission Saunders, An Imprint of Elsevier Science. Darby, M. L., Walsh, M.M., Eshenaur Spolarich, A. Persons with disabilities In: Darby and Walsh. Dental Hygiene Theory and Practice. 2nd ed. St. Louis, Mo.: Saunders; 2003: 774.

Figure 3 and 4--Reprinted with permission from the Southern Association of Institutional Dentists. Southern Association of Institutional Dentists. Preventive Dentistry for Persons with Severe Disabilities. Module 11. Self-Study Course (a series of 15 Modules) available at: http://saiddent.org/modules.asp. Accessed October 10, 2008. (8): 1141-43.

Janet Jaccarino, CDA, RDH, MA, is an Assistant Professor in the Department of Allied Dental Education, in the School of Health Related Professions at the University of Medicine and Dentistry of New Jersey. She has been teaching dental hygiene and dental assisting students since 2000 and can be reached at jaccarja@umdnj.edu.
Table 1

Skill Level Evalutation (2)

HIGH LEVEL       * The patient can brush and floss his or her own
                   teeth.
                 * May only need encouragement, motivation and
                   supervision.

MODERATE LEVEL   * The patient needs partial care.
                 * The patient can carry out part of his or her oral
                   hygiene.
                 * The patient requires considerable training,
                   assistance and direct supervision.
                 * Assistance may be verbal or require hand-over-hand.

LOW LEVEL        * The patient requires total care provided by a
                   parent or caregiver.
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Title Annotation:Clinical
Author:Jaccarino, Janet
Publication:The Dental Assistant
Article Type:Report
Geographic Code:1USA
Date:May 1, 2009
Words:3128
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