Good oral hygiene is essential to prevent dental decay and gum disease. With the proper daily use of dental hygiene tools, a low level of oral bacteria can be easily achieved. This will result in a reduction of bad breath, in fewer cavities and in a healthier gum tissue that does not bleed. Studies have linked poor oral health with cardiovascular disease, low birth weight babies, lung infections and even cancer. People whose immune systems are compromised, for example those who are taking immunosuppressant drugs, are especially susceptible to systemic effects of poor oral health and must have clean mouths in order to avoid systemic complications such as lung infections. We recommend that the dentist or allied dental health care provider follow these general steps in order to conduct a complete and thorough oral hygiene instruction session. These steps should be modified, of course, according to each patient’s individual needs.
1. Patient orientation and introduction to their mouth
The dentist begins by showing the patient his/her own oral tissues up close. For example, the ‘gums’, teeth, exposed root surfaces and tongue can be visualized using a hand mirror and the overhead dental lamp.
This can be followed up by using an intra-oral camera to point out details that can’t be visualized with the hand mirror.
The dentist discusses the relationship between plaque and caries using available teaching aids (use a good diagram of a tooth covered in plaque or a cut-away diagram with caries penetrating enamel, dentin and pulp).
The dentist then turns to the radiographic images on the computer and introduces the patient to simple landmarks relating to what is seen on the radiographs. For example, the dentist could point out that darker images, such as the nerves in the teeth, soft tissues and even cavities are low in calcium and appear dark, while the white images are fillings: they block the x-rays and prevent them from reaching the film or the computer sensor.
The dentist could take this opportunity to point out obvious plaque, if it is prominent. Use a periodontal probe to pick up a sample of plaque to show the patient while the patient is watching in the hand mirror.
Step 2: Disclose and let the patient demonstrate his or her usual hygiene practices
No oral hygiene instruction session is complete without using a disclosing dye. The dentist instructs the patient on the appropriate use of the disclosing tablet or solution. Use Butler “Red Cote” tablets or drops, or Two-Tone.
Tablets are chewed thoroughly, all teeth should be licked, then the solution swished and spit out, followed by at least two water rinses. Alternatively, the dentist and assistant can rinse and suction out the excess solution.
Solutions are more convenient because they do not require chewing.
A blast of air form the air-water syringe is used to reveal the stained plaque.
If the patient is very young, paint on the dye with a cotton swab, rinse with the air-water syringe, suction with the saliva ejector…and make it fun!
This is also an opportunity to show the parent or guardian how effective brushing was.
For patients who conduct their own hygiene, demonstrate the stained plaque to the patient with a hand mirror, indicating the areas that were missed. Then, the dentist asks the patient to show him or her how oral hygiene is normally carried out at home. Some patients have trouble getting all the plaque off despite having just seen exactly where they missed with the toothbrush.
The dentist encourages the patient even if he or she is not able to brush effectively.
At this stage, any problems in dexterity or oral hygiene ineffectiveness are noted in the chart.
Step 3: Demonstrate appropriate brushing technique
Using a tooth brush specifically selected for the age of the patient, the dentist demonstrates an appropriate tooth brushing technique in the patient’s mouth as the patient looks on in the hand mirror.
If the patient is a child, the demonstration of the simple ‘roll’ technique should be conducted in the child’s mouth with a parent present. For very young children, scrubbing back and forth is acceptable.
For teens and adults, the Modified Stillman technique should be introduced.
Once demonstrated, the patient should be encouraged to try the technique (while the dentist holds the hand mirror).
The patient inspects his or her teeth to observe that more plaque was indeed removed
Step 4: Introduce flossing
Brushing only cleans a portion of one’s teeth, but it cannot clean between them where most gum disease and cavities are found. The best way to clean between the teeth is to floss.
Floss comes in many shapes, styles and flavours. Encourage patients to find the one they like and use it regularly.
The Dentist will demonstrate proper flossing technique to the patient by starting with a long piece of floss.
Wrap it around the middle fingers so that it can be comfortably held. For the lower teeth, hold the floss with the index fingers. For the upper teeth, hold the floss with the thumb and forefinger.
Gently slide the floss between the teeth. Wrap it around one tooth in a ‘c’ shape and carefully slide it under the gum line, moving it gently up and down along the side of the tooth.
Next, move the floss across to the neighboring tooth, being careful not to damage the gums, and repeat by wrapping the floss in a “c” shape around this tooth and moving it up and down as before.
Remove the floss and repeat the same steps between all other teeth. Remind patients to floss the back of the last teeth.
As with brushing, using the same pattern every time will make this process fun and enjoyable. Encourage patients to keep in mind that flossing will take time, so they should be patient. Practice makes perfect.
To demonstrate use of a proxa brush, gently pass the brush behind the wire of a fixed retainer, between spaced teeth at the gum line or under a bridge, while moving the brush in a circular motion, then back out. This should be repeated until all areas of the appliance or all spaces have been cleaned.
Superfloss can be used under bridges or behind fixed retainers such as those that may have been placed after having braces. Insert the stiff end underneath or behind the dental work and pull through. Use the softer, larger end as you would regular floss. Press the floss against the tooth in a ‘c’ shape and move it gently up and down against the side then repeat on the adjacent tooth.
A floss threader can be used to floss with regular floss under bridges or behind fixed retainers. Simply thread the floss through the loop of the floss threader then slide the threader below the bridge or behind the retainer until one end of the floss is on each side. Grab hold of each end and floss as normal.
A sulca brush is convenient for getting behind teeth and at the gum line. Simply run the tip gently along the gum line to remove the plaque.
Patients with dental work that makes cleaning their teeth more complicated will require them to take a bit more time, but using the techniques described, there is no reason why they can’t maintain healthy gums and teeth.
Again, remind patients brushing and flossing takes patience and it may take time to become comfortable with the proper techniques.
Establish for the patient that brushing two times daily and flossing at least once a day will help to maintain a healthy smile, but encourage regular visits to the dentist as well. With good home care and routine check-ups, dentist and patient can work together to maintain a healthy smile for life.