Oral Hygiene and

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					                                           Employee Orientation and Training Manual

                               Section 11
                              Oral Hygiene

Policies to Be Read:

If you support people with Developmental Disabilities:

 7.3 Healthcare – Sanitary Practices

Estimated time to complete this section:      1 hour

    Ask your Supervisor to check off these areas on your Orientation
     Checklist after you have read them.

                You will need your Orientation Workbook and a pen to complete this

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At the end of this module you will be familiar with the following concepts.

   o I will be able to discuss why good oral hygiene is important for the people I


   o I will be able to discuss the process and safety of assisting someone with his or

      her oral hygiene needs.

   o I will be able to demonstrate my skills in properly assisting someone with their

      oral hygiene routine.

   o I will identify ways that medication may affect a person’s oral hygiene.

The knowledge you gain is directly correlated to the following Personal Outcome

    People have the best possible health.

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1.     Why are Good Oral Hygiene and Dental Care Important?

A person’s oral hygiene and dental care can have a direct effect on his or her overall
health status. If a person’s teeth or gums are not healthy, he or she may experience
pain and discomfort. This can affect what and how well he or she will eat. A person’s
ability to speak may also be affected by dental problems. It is vital for all people to
practice good oral hygiene and to participate in a dental care routine.

People with disabilities often have concerns (health, physical, behavioral, etc.) which
may complicate their oral hygiene and dental care. This module will give you some
basic information about this topic and will provide opportunities for you to use the
training materials to better fit the needs of the people you support.

2.     The Role of Plaque

Before we get into the specifics of promoting good oral health, we need to talk about the
major contributing factor to dental disease. Plaque is a clear, sticky coating of
bacteria and their byproducts that forms on the teeth. It accumulates in the pits
and fissures of the teeth, along the boundaries between the teeth and
gums, and in cracks, defects and rough surfaces. If plaque is not
thoroughly removed every day, it can cause the two main enemies of good
oral health, tooth decay and gum disease. We will talk about prevention of
plaque build up later.

3.     Tooth Decay

While we tend to associate tooth decay with children, it’s important to understand that it
isn’t just a children’s health problem. Adults of all ages are susceptible to decay.
Tooth decay occurs when the protective coating on our teeth, called enamel, breaks
down. The culprits are foods containing carbohydrates (sugars and starches). Plaque
bacteria convert the sugar and starch into acid. Each acid attack may last twenty
minutes or more. After many attacks, the tooth enamel breaks down, resulting in a

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Children are especially at risk because of the small pits and fissures on the chewing
surfaces of their teeth. Some of the areas are so small that even a single toothbrush
bristle cannot reach inside.

Adults, on the other hand, are more prone to decay around the roots of their teeth. This
is because as we age, our gums begin to recede, exposing the root of the tooth. Tooth
roots are much softer and do not have the protection of enamel.

4.      Gum Disease
Gum disease is an infection of the gums which is caused by a film of bacteria that coats
everyone’s teeth. Gum disease can occur at any age, but it is most common among

In the early reversible stage of gum disease, called gingivitis, gums can become red,
swollen and bleed easily. When the disease progresses to the bone, which supports the
teeth, it is called periodontitis and at that point can cause irreversible damage. In the
advanced stage of the disease, the bone and soft tissues, which support the teeth, are
destroyed and this may cause the teeth to become loose, fall out, or have to be
removed by a dentist.

Gum disease is caused by the bacteria that attach to the crown and root surfaces of the
teeth. These bacteria organize to forma film called dental plaque. Because plaque is
sticky and constantly forms on the teeth, it can continue to build up on the teeth and
gums. If plaque is not removed through daily cleaning, it produces toxins or poisons that
can irritate and inflame the gums. Eventually these toxins destroy gum tissues, causing
the tissues to separate from the tooth and form deepened spaces called pockets. The
pockets can then hold more bacteria, and the process can progress so that the gum
tissues detach even further until the bone and supporting tissues of the teeth are

             Question: What are the benefits to a person’s health to have good oral

5.      Oral Hygiene

The main components of oral hygiene are:

     o tooth brushing
     o flossing
     o cleaning of the tongue and other parts of the mouth.

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Staff who work with people with disabilities may have numerous roles in assisting in the
oral hygiene process. The degree of support you will need to provide is determined by
the unique, individual needs of the people you support. Some people will be able to
become independent in their own oral hygiene. Many others will need varying amounts
of training and support in order to meet their oral hygiene needs; and some will need
total support from staff in order to maintain good dental health.

The person and his or her interdisciplinary team will make decisions about the level of
training and/or assistance he or she will need. You will review specific procedures for
each person you support later. In some cases, you may encounter a person who does
not wish to have you assist them with oral hygiene. Sometimes, people will actively,
even aggressively, resist oral hygiene. You will be given information about how to assist
the person with these situations.

A. Preparation for Assisting with Oral Hygiene

Before you begin to assist a person with their oral hygiene,
   o you must talk with person about what you would like to do to assist them
   o follow sanitation precautions
   o be familiar with specific programs or procedures for the person
   o assist in preparing the environment and equipment which will be used

1) Preparing

   You should first make sure that the person understands and anticipates what is
   going to happen. Explain the procedure to the person in a way that he or she will
   understand including what you will be doing for them and what their participation will
   be. Some people may need specific relaxation techniques to ready them for having
   their teeth brushed. Be aware that, for some people, having their teeth, mouth or
   head touched by another person may be threatening and disturbing. Use slow,
   calm movements so as not to startle the person. It helps to have a well lit but relaxed
   atmosphere with a minimum of other activity and noise.

2) Safety and Sanitation

   Whenever you assist someone with personal hygiene tasks, you must first take
   precautions to prevent the spread of illness and disease, both for yourself as well as
   the person you are assisting.

   Hand washing is of utmost importance. Before you begin, thoroughly wash your own
   hands and assure that the person you are assisting washes his or her hands,
   assisting them when necessary. (Hand washing procedures are explained in detail in
   the LSS’ Exposure Control Plan.)

   Since oral hygiene procedures can potentially involve contact with the person’s
   blood, you should take appropriate universal precautions. To briefly review, you
   need to protect yourself from contact with blood by wearing the appropriate

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    protective clothing. Vinyl or latex gloves should be worn after washing and drying
    hands. In some cases, particularly if you are using an electric toothbrush or water
    pick which can cause splattering, you may need to wear protective eye/face wear
    and aprons, gowns, etc. Your supervisor will review the appropriate precautions to
    use in your program.

3) Reviewing Programs/Procedures

    Make sure that you fully understand any specific procedures to use with the person.
    If necessary, ask your supervisor for clarification of any portion you don’t fully

4) Environment/Equipment

    Oral hygiene should take place in the bathroom or other private place. Personal care
    tasks should not take place in common areas of the home such as the kitchen,
    hallway, etc. The person’s dignity and privacy should always be protected. You
    should have the person participate as much as possible in preparing the necessary
    equipment and supplies.

5) Proper Positioning for Oral Hygiene

    For people who require physical assistance during oral hygiene, proper positioning
    can often make the difference between a pleasant, efficient procedure or
    uncomfortable, poorly done job. It is important to note that positioning must be
    individualized to the needs of every person. The following suggestions are fairly
    general and the people you assist may have more specialized positioning
    procedures which you will need to follow. When in doubt, ask your supervisor.

     Wheelchair:
       Stand behind the wheelchair. Use your arm to brace their head against the chair
       or your body. You may wish to use a pillow for comfort.

     Foam chair or beanbag chair:
      People who have difficulty sitting up straight may find that a foam or beanbag chair
      will allow them to relax without the fear of falling. Position yourself next to the
      chair, using your arm to support their arm and body.

B. Tooth Brushing

    Brushing teeth removes plaque and particles of food from the surfaces
    of teeth. It is recommended to use a brush with soft bristles, which is
    small enough to easily reach every tooth. Toothbrushes should be
    replaced every three or more months. We will now review the method for

                                                                           Oral Hygiene
  brushing teeth. Remember that brushing teeth incorrectly or in a haphazard fashion
  will do little to prevent tooth decay.

  Place tooth brush bristles at the gum line at a 45% angle to gums. Press gently
   and use short strokes with a vibrating, back and forth or light scrubbing motion.

  Start with upper teeth, brushing inside and chewing surfaces. Do the same for the
   lower teeth. Be sure to brush each tooth.

  Reposition brush vertically to clean inside surfaces of front teeth, both upper and

  Remember to brush the tongue, as it can harbor many bacteria.

C. Flossing

   If you don’t floss, you’re really doing only half the job necessary to clean teeth and
   gums properly. Brushing generally cleans only the tops, front and back of the teeth,
      but it doesn’t clean the tooth surfaces between the teeth. This means that 40% of
           your tooth surfaces remain uncleaned with brushing alone.

           Using the following procedure at least once each day will help prevent the
  build up of plaque between your teeth:

   Break off about 18 inches of floss and wind most of it around one of your middle
    fingers. Using a loop of floss may be easier. In addition, for those people who
    have difficulty in manipulating floss, commercial floss holders might be helpful.

   Wind the rest of the floss around the same finger of the opposite hand. This
    finger can “take up” the floss as it becomes soiled.

   Use your thumbs and forefingers with an inch of floss between them to guide the
    floss between your teeth.

   Holding the floss tightly (there should be no slack), use a gentle sawing motion
    to insert the floss between the teeth. Never “snap” the floss into the gums! When
    the floss reaches the gum line, curve it into a C-shape against one tooth and
    gently slide it into the space between the gum and the tooth until you feel

   While holding the floss tightly against the tooth, move the floss away from the
    gum by scraping the side of the tooth.

   Without removing the floss, curve it around the other tooth and scrape it too.
    Scrape floss down on the upper teeth and up on the bottom teeth.

                                                                            Oral Hygiene

  Repeat this method on the rest of the teeth. After brushing and flossing, the
   mouth should be thoroughly rinsed with water or a mouthwash to flush away
   dislodged food particles and plaque from the tongue and cheeks.

        Question: What is the process for assisting someone with his or her oral
        hygiene routing?

6. Dental Care

The cornerstone of good dental care is making regular visits to the dentist. Dental
visits should occur at least once a year and more frequently if the person’s condition

It is important that the dentist be sensitive to the needs of persons with disabilities.
This can play an important role in familiarizing the dentist with the person’s individual
characteristics and needs. Depending on the person’s needs and feelings about
dental visits, sometimes a phone call or meeting in advance of the appointment can
result in the dentist and the office staff being more aware of how to best respond to
the person. This also allows both of you to work out how to accommodate any special
needs. It is better to try to work out solutions to potential barriers or obstacles in
advance of the visit whenever possible.

Be aware that when you talk to the dentist or staff (or any other service provider, for
that matter) that you provide a positive example by speaking in positive, people-first
language and that you refer to the person in an age appropriate manner. It is also
important when in the person’s presence to speak to the person directly or involve
them in the conversation as opposed to talking about them in the third person.

It is important to prepare the person for their visit to the dental office. Some people
find this a threatening and even frightening experience. Support the person to help
them be as comfortable as possible. Explain what is likely to happen during the visit in
a way the person can understand. Some people who are very nervous about a visit to
a new dentist or clinic may be comforted by visiting the office in advance of the visit.

7.     Special Considerations

A. The effects of medication

                                                                          Oral Hygiene

      Certain medications can cause or worsen certain dental problems. Some
      seizure controlling medications may cause gums to grow over the teeth or to
      swell and bleed easily. Oral contraceptives, steroids and cancer therapies can
      also affect the gums. Liquid medications, which are suspended or dissolved in
      a syrup base can also promote decay.

          Question: Who has medications that may interfere with their oral health?

        B. Caring for Dentures

      Daily cleaning and regular dental visits are essential for everyone, including
      people with dentures, Each day, before dentures are inserted, the gums,
      tongue and palate should be brushed with a soft bristled brush to remove
      plaque and stimulate circulation. Dentures also need cleaning on a daily basis
      to remove plaque, food particles and to prevent staining.

     All denture wearers should continue regular dental visits. Besides
     checking the dentures, the dentist will check for signs of oral
     cancer and examine the gum ridges, tongue and jaw joints.

      If dentures break, crack or chip, or if a denture tooth becomes loose, call a
      dentist right away. Dentists can usually repair broken dentures, often on the
      same day.

C. Modified Equipment

    Many people have hand, arm or shoulder problems which limit their ability to
    brush and floss. Some of the following suggestions may help people to brush and
    floss without assistance from others.

       Attach the toothbrush handle to the hand with a wide elastic band.

       Enlarge the toothbrush handle with a sponge, rubber ball or foam grip.

       Lengthen the toothbrush handle with a piece of wood or plastic, such as a
        ruler or a wooden tongue blade.

       Bend the toothbrush handle. This can often be done by running hot water
        over the handle of the brush.

       Use an electric toothbrush.

       Use a commercially available floss holder.

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8. Specific Individual Issues

     At this point (if you have not already done so) your supervisor will arrange for you to
     review the specific needs, programs, and equipment for oral hygiene and dental care
     of the people you support in this program.


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