Home > Encyclopedia of Nursing & Allied Health > Oral Hygiene

Definition

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing, flossing, and using appropriate therapeutic aids to prevent caries (tooth decay) and periodontal disease.

Purpose

The goal of proper oral hygiene is to control plaque, the sticky bacterial film that continually forms on teeth. Plaque adheres to the crevices and fissures of teeth and, when not removed on a regular basis, generates acids that can decay the enamel surface of teeth. Plaque is also a physical and a chemical irritant to the periodontium, the tissues investing and supporting the teeth.

Toothbrushing and flossing remove plaque from teeth, and antiseptic mouthwashes kill some of the bacteria in plaque. Fluoride—in toothpaste, drinking water, or dental treatments—also protects teeth by binding with enamel to make it stronger. Despite a patient's best efforts, plaque formation can lead to calculus formation. Calculus, also called tartar, is an adherent, calcified deposit made up of dead bacterial cells from plaque. Calculus does not cause tooth decay, but is a primary cause of periodontal disease. Calculus can only be removed by a dental professional, therefore regular dental visits are essential to good oral hygiene.

Precautions

Brushing should be performed thoroughly and gently with the correct brush, refraining from "scrubbing" at the teeth with too much force. Brushing that is unnecessarily vigorous can cause gum irritation, gum recession, and abrasion of tooth structure. Flossing can also be performed too vigorously. A patient who inserts floss between teeth, then "saws" back and forth with downward force can create fissures in gum tissue that destroy the attachment of gum to tooth.

As deciduous (primary) teeth erupt, caregivers should develop the habit of brushing children's teeth after every meal. Since excess ingested fluoride can cause dental fluorosis, a mottled discoloration of tooth enamel, care should be taken that the child does not swallow any toothpaste. A pea-size amount of fluoridated toothpaste is all that is necessary to clean a child's teeth. Fluoride-free toothpaste for children is available.

Patients with full or partial prostheses are not exempt from the need for good oral hygiene. Dentures should be removed daily, cleaned with a brush and rinsed or soaked in a denture cleansing bath. Gum tissue should be brushed and rinsed to remove food particles and bacteria. If possible, dentures should be left out at night to allow the tissues to breathe without pressure from the prosthesis. When not in use, dentures should be covered with water or a denture cleaning solution to prevent drying. Dentures should be adjusted, relined, and replaced when necessary by a dentist.

Fixed prostheses such as bridges and implants require special cleaning tools for proper maintenance and to prevent failure of the prosthesis.

Description

Using a toothbrush

Ideally, patients should brush after every meal and snack with a fluoride toothpaste. Following a set routine ensures that no teeth are missed. A recommended sequence is to start on the upper right outside surfaces, continue to the upper left, switch to the inside left surfaces and return to the inside right. Then brush the occlusal (chewing) surfaces of the back teeth, move to the bottom and repeat the same sequence. The tongue should also be brushed to remove odor-causing bacteria. A thorough tooth brushing should take two to three minutes.

The American Dental Hygienists' Association recommends the following technique:

• Place toothbrush bristles along the gumline at a 45-degree angle. Bristles should contact both the tooth surface and the gum.

• Gently brush the surfaces of two or three teeth using a vibrating, back and forth rolling motion. Lift the brush, move it to the next group of two or three teeth, and repeat.
• Behind anterior teeth, tilt the brush vertically. Make several up and down strokes using the front half of the brush.
• Place the brush against the occlusal (chewing) surface of the teeth and use a gentle back and forth scrubbing motion.

Consumers should look for a toothbrush with soft, nylon, end-rounded bristles in a size and shape that allows them to reach all tooth surfaces easily. Power toothbrushes are available in various styles, and have been proven to be as effective as manual toothbrushes. Research has found no significant differences in plaque reduction between manual and powered tooth brushing.

For those with limited use of their hands, toothbrush handles can be inserted in a small ball, bicycle grip, or sponge hair curler for easier gripping. Children's toothbrushes typically have larger handles, and may be appropriate for adults with less flexibility.

Toothbrushes should be replaced every three to four months, since bristles lose their integrity and don't clean as well after a period of time. In addition, toothbrush bristles and handles collect microbes that can cause colds, the flu, herpes, and periodontal infections. Some brushes have colored bristles that lose their coloration gradually, prompting a patient to replace it when the color is gone.

Using floss

Using dental floss daily to clean between teeth has many benefits. Interproximal (between adjacent teeth) decay is prevented because plaque is removed; interproximal restorations are maintained in healthy condition; and the sulcus surrounding each tooth is kept free from plaque and associated pathogens, ensuring periodontal health. Floss comes in many varieties (waxed, unwaxed, flavored, tape), and may be chosen by personal preference. As with brushing, flossing is easier for a caregiver when he or she is positioned behind the patient.

To begin, one end of an 18-inch piece of floss is wrapped around the middle finger of one hand. Most of the rest of the floss is wrapped around the middle finger of the opposite hand, leaving a one- to two-inch center section that is grasped between the thumb and forefinger of each hand. The floss is eased between two teeth with a gentle back-and-forth motion, then pressed in a c-shape against one tooth, covering as much tooth surface as possible. The floss is worked gently up and down, back and forth, in and out to clean and scrape plaque from the side surface of the tooth, both above and below the gumline. The floss is then lifted over the papilla (raised gum tissue between teeth), and the process is repeated on the opposite tooth. As floss becomes soiled, fresh floss can be released from one hand, and used floss taken up by the other hand.

Using therapeutic aids

Toothpicks, both wooden and plastic, can be used as interdental cleaners. Small interdental brushes are also useful for cleaning wide spaces between teeth and under bridgework. Flossing can be made easier with floss holders. For flossing under fixed bridgework and around implants, floss threaders can be used, or floss with a stiff leader attached to one end.

Complications

Gingivitis is the immediate consequence of poor oral hygiene. An early form of periodontal disease, gingivitis is characterized by inflammation of the gums with painless bleeding during brushing and flossing. This condition is reversible with proper dental care, but if left untreated will progress to periodontitis. A professional cleaning by a hygienist or dentist is indicated, followed by home care instruction.

Periodontitis is a disease of the support structures of teeth, the gums, ligaments, and bone. Without support, teeth will loosen and may fall out or have to be extracted. To diagnose periodontitis, a dental professional looks for gums that are red, swollen, bleeding, and shrinking away from the teeth, leaving widening spaces between the teeth and exposed root surfaces vulnerable to decay. Measurements are taken in the sulcus—the space between tooth and gum—to determine the level of attachment of tooth to gum and bone. Studies may be undertaken to measure bacterial load in the sulcus. A general dentist is qualified to treat periodontitis. Some choose to specialize in this area, and are called periodontists. Treatment for periodontitis may include detailed home care instruction, specialized prophylaxis, antibiotic therapy, surgery, or a combination of the above.

Caries, or tooth decay, is a common consequence of poor oral hygiene when acid from bacterial plaque is allowed to form. A dentist will remove the decay, prep the clean cavity, and fill it with an amalgam or resin restoration. Left untreated, decay can expand, destroying the entire tooth and causing significant pain.

Results

With proper home care, oral hygiene may be maintained and oral health problems may be avoided. Older adults no longer assume they will lose all their teeth in their lifetime. Regular oral care preserves appearance, speech, and eating functions, thus prolonging the quality of life. Without proper home care, the patient runs a significant risk of losing teeth prematurely from decay or periodontal disease.

Health care team roles

Dental professionals monitor their patients' oral hygiene practices, making recommendations and providing instruction when necessary. During routine recall visits, a hygienist will typically review home care and make suggestions.

Caregivers such as nurse's aides are critical team members when it comes to oral hygiene. A patient who cannot brush and floss for himself or herself may compromise overall health by exposure to decay or periodontal disease.

Patient education

Patients receive oral hygiene training throughout life, first from parents or caregivers, then from educators, then from dental professionals. A child may be taught to brush by his or her mother, then have that training reinforced by a school health educator. As children begin to visit the dentist regularly, they receive further training at routine visits. Flossing instruction is usually given at the dental office or in school, once permanent teeth have erupted and the child has enough manual dexterity to learn this skill. As the child becomes an adult, the hygienist or dentist can reinforce prior training and make any adjustments necessary.

Training

Health educators and caregivers can receive training from dental professionals to help their students and patients achieve good oral health. In-service programs are available from dental associations and boards, state health boards, and sometimes from local dental offices.

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KEY TERMS

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Calculus—An adherent, calcified deposit of bacteria, fungi, desquamated epithelial cells and food debris, formed on the surface of teeth. Also known as tartar.

Caries—Tooth decay.

Fluorosis—Mottled discoloration of tooth enamel, caused by excess systemic intake of fluoride.

Gingivitis—Swollen, bleeding gums, usually not painful.

Periodontitis—A gum disease that destroys the structures supporting the teeth, including gums, ligaments, and bone.

Plaque—A thin, sticky, colorless film of bacteria that forms on teeth.

Sulcus—Pocket space between tooth and gum.

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Cathy Hester Seckman, R.D.H.