Caring for our own mouths is a challenge—but for the mouths of others, even more so. Carers, family members, hospital workers and parents can all be called upon to look after the teeth and gums of those in their care and usually very little training is provided as regards this intimate task. Cooperation can be varied, and knowledge about adjuncts to oral care can be limited.
Teeth brushing should take place twice daily, ideally for three minutes, and using a toothpaste with at least 1000ppm of fluoride. When placing the toothpaste on the brush, it should be mashed into the bristles, which reduces the chance of it sliding off the brush and being swallowed. Brushing removes debris from the tooth surfaces, plaque from the gum line; the toothpaste provides fluoride, which helps to remineralise the enamel surface and therefore strengthen the teeth.
Regarding brushing technique, it is important to use the right tools to make the task as easy as possible. For persons with reduced dexterity, an ordinary toothbrush can be made easier to grip by padding the handle. Collis Curve toothbrushes are designed to remove plaque more effectively and they are ideal for those with disabilities who clean their own teeth, or for their carers. These brushes can also be effective in a shorter timespan than ordinary brushes. They have a relatively small head and distinctive bristle shape, which has been shown to improve gingival health by up to 68%. These can be very useful, as can electric toothbrushes, in maximising plaque removal in a limited time and with less manual exertion. Brushes should be replaced every three months, although some may wear out sooner.
Gingival health is often a major source of tooth loss for adults with disabilities. Bleeding on brushing is common and it is a sign that gums need to be brushed more. Persistent bleeding is an indication that professional advice should be sought. Flossing can be difficult, requiring a good deal of dexterity, time and cooperation, but it is necessary in maintaining gum health. Tepe brushes are small brushes for cleaning between the teeth and, combined with floss harps, they can be an excellent alternative to normal flossing. With floss harps, the floss is already threaded on a small harp which can be held easily between the forefingers and manipulated between tooth surfaces.
Disclosing tablets are a very useful and clear way of assessing the effectiveness of brushing and flossing—both personally or when caring for the teeth of others. The tablets are most effective when used after brushing. They are chewed, swished round the mouth and then spat out. They stain areas where plaque remains (usually pink or blue) and can highlight the areas that have been missed when brushing. After using the tablets, the missed areas can be brushed again.
Access and cooperation are major challenges when trying to clean the teeth of others. Brushing teeth is a fairly invasive task and the process may be met with some resistance. Establishing a consistent routine is important—starting slowly, allowing the patient to get used to the feel of the brush in the mouth and the taste of the toothpaste. Building up full dental cleaning can take some time. The mouth is sensitive and gagging is not uncommon, and it is important that people should not associate toothbrushing with pain or vomiting. The patient may need breaks, as keeping the mouth open for prolonged periods may be difficult for some.
It important always to explain to the patient in advance exactly what is going to happen, and to do the brushing in a place and a position in which they are comfortable and relaxed to maximise cooperation. Brushing in front of a mirror is ideal, as it can allow patients to watch what is happening. Usually standing slightly to the side of the patient gives the best access, but moving around the patient for brushing various areas of the mouth may be necessary. Ensure the patient’s head is supported and that there is good lighting, so that the teeth and gums are clearly visible even towards the back of the mouth. Playing a song can be a good way of ensuring that brushing has lasted an adequate time and it can also help to relax the patient, especially if they come to associate it with the routine of brushing.
Home care is paramount, but so is ensuring that those in your care are regularly seen by a dentist. Six-monthly or annual check-ups are recommended by the NICE guidelines. This can ensure early detection of tooth cavities, gum disease or more serious oral complaints such as mouth cancer. The interval between check-ups may vary from patient to patient, but as those with an intellectual disability may be at a higher risk of untreated decay, more frequent check-ups are recommended. In caring for the mouths of others, perseverance is important. Improvements and cooperation can be gradual. It is important to seek advice if you notice something unusual or worrying when assisting in the care of others.