May 2021 Volume LVI Number 3


Adapting Oral Hygiene Recommendations for Individuals with Special Health Care Needs

November 2020 Volume LV Number 6

by the AAPD Special Health Care Needs Committee
Jessica Listwa, DMD, Pediatric Dentist, Private Practice, Central N.J.
Elizabeth S. Gosnell DMD, MS, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio Associate Professor, Division of Pediatric Dentistry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
Children or adults with special health care needs (SHCN) may require adaptations to achieve optimal oral health care. Modi- fications may be needed in order to provide oral hygiene care at home and in the dental office. The purpose of this commu- nication is to give a brief overview of modifications that may benefit your patients with special health care needs.
While many providers may be familiar with these adaptations, the purpose of this communication is to place a focus on this population, remind pediatric dental providers of these tech- niques, and provide this information for those pediatric den- tists who may not know this information or are not currently comfortable seeing this population in their practice. It is also to provide resources on oral hygiene adaptations for your caregiv- ers of individuals with SHCN.
Here is a compilation of different adaptations, tips and tricks to help the provider ultimately help the parents and caregivers of individuals with special healthcare needs. These simple adapta- tions can have everlasting effects on individuals with SHCN’s oral health care and overall health and quality of life.
Toothbrush adaptations:
For those who are able to brush their own teeth, an electric toothbrush may make brushing easier and more efficient once they adapt to it. However, for individuals that are unable to ac- complish brushing using a traditional or powered toothbrush, there are simple ways to modify brushing with different tools, instruments, and positioning. Here are some quick and easy tips to modify a toothbrush to make it more usable for different abilities.
1. Expanded grip capability. For some individuals, adding a larger grip to the toothbrush allows them to hold and manipulate the brush themselves. This can be done by:
  • Purchasing a brush with a larger handle. Some com- panies already produce toothbrushes with a bigger handle for better gripping.
  • Making a slit into a tennis ball and sliding the bottom of the toothbrush handle into the tennis ball.
  • Sliding the bottom of the toothbrush into a bicycle handle grip or any type of rubber or even foam tubing.
  • Wrapping a small cloth around the bottom of the brush.
  • Attaching a Velcro strap around their hand and the toothbrush or a wide elastic or rubber band around the hand and toothbrush for added stability, ensuring they are not too tight.
2. Change to toothbrush shape or dimensions. Some indi- viduals might require changes to the shape of the tooth- brush to make it angled for better access to their teeth. This can be done by:
  • Purchasing a brush that is bent to a more useful angle for brushing. Some companies produce bendable brushes available at local convenience stores.
  • Running the toothbrush handle (avoiding the bristles) under hot water so that you can gently bend the plastic according to your needs.
  • Other individuals might need a longer brush to better reach their mouth to be able to brush on their own. To elongate the toothbrush materials can be added, such as taping several popsicle sticks to the bottom of the brush or adding some type of tubing to the bottom.
  • Purchasing a triple-headed toothbrush (Specialized Care Co, Hampton, N.J.) is very helpful for either the patient or caregiver to use to brush all surfaces of the teeth at the same time.
Toothbrushing adaptations for caregivers:
For those individuals who are unable to complete oral hygiene tasks independently, a challenge for their caregiver may be keeping their mouths open long enough to accomplish tooth brushing. Caregivers can buy commercial products to use at home, such as the Open Wide Mouth Rest (Specialized Care Co, Hampton, N.J.), available at various websites. Other commercial products widely available include the molt mouth prop and bite block. Practitioners should inquire what caregivers are using to accomplish oral hygiene and discuss proper safety pre- cautions of these products. Caregivers can also make their own device to help keep their children’s mouths open with common household items. Examples of these are a clean rubber door stopper, three to four popsicle sticks taped together, or a rolled moistened cloth.
Some individuals are not able to complete oral hygiene tasks independently. And some may move or struggle, making completing oral hygiene difficult for their caregivers. Here are several positioning techniques to consider that may assist the caregiver.
  1. Therapeutic wrap. This is a gentle and light wrap that will calm the individual and limit his or her movement making it quick and easy to brush for them. One or two simple wide sports wraps can be used, purchasable at any sporting goods store or pharmacy. Place the individual in a chair or their wheelchair, place their arms on the sides of their body, place the wrap behind the back around the front and Velcro closed to keep their arms down. If needed, repeat with a second wrap higher than first wrap. The caregiver should ensure the wrap is soft and that it is not too tight. It is imperative that these wraps not be used to ‘straighten’ patients who are spastic at rest or have a restricted position.
  2. Caregiver sitting in a chair. One way to make brush- ing easier is to sit in a chair and position the individual sitting on the floor facing away from you in between your legs. This is very simple and allows you to have easy access and control. Position the individual in between your legs while you sit in the chair. If they begin to move, you can lighten tighten your legs or even wrap your legs around them. Position one hand under the chin so that their head is reclined for better access and visualization to the mouth.
  3. Using a couch/ bed/ floor. While you sit on the couch or bed, position the individual to have their head on your lap. This allows you easy access and control. Position the individual’s hands by their sides. If they move a lot, cross the individual’s hands and have a second individual hold the hands. If you do not have a second individual, you can position your legs so that they cross over the individuals’ arms. Use one hand to support the head and place the chin up for visualization.
  4. Using a bean bag chair. Have the individual sit in a bean bag and then you are able to position yourself behind him or her. Position yourself behind the individ- ual- either sitting or standing depending on how tall the individual is on the bean bag. Position the individuals’ arms to the side. If the individual is moving, then have a second individual help hold the arms. Position your hand under the chin to lift and support the head.
For individuals who need assistance with oral hygiene, caregivers can use the suggestions above to help keep their mouth open while flossing, either with a floss holder or with regular string floss, depending on the individuals’ ability to tolerate this task.
Toothpaste adaptations:
Many parents with children or adults with special heath care needs, specifically those with oral sensitivity, struggle to find a toothpaste that their child can tolerate. The individual is most likely sensitive to either the taste or the consistency of the toothpaste. The importance is to find a toothpaste with fluoride that the individual can tolerate. To combat sensi- tivity to the taste, encourage parents to try untraditional toothpaste flavors such as those produced by Hello Products with fluoride (Montclair, N.J.), Tom’s of Maine with fluoride (Kennebunk, Maine), and Tanner’s Tasty Paste (New London, Conn.). Recent unconventional flavors have been developed such as vanilla and chocolate ice-cream, orange, mango and even matcha. While others are unable to tolerate any taste at all, Oranurse Fluoride (UK) toothpaste with zero flavor can be a great alternative. Not all of the products listed have the ADA seal of approval and practitioners should evaluate products prior to recommending their use.
Many individuals with oral sensitivity are unable to tolerate the foaming nature of toothpaste. This foaming is attributed to the ingredient commonly found in toothpaste, Sodium Lauryl Sulfate (SLS). More recently, many toothpaste compa- nies have products that are SLS free and would say specifi- cally so on the toothpaste tube or packaging.
For others who are unable to tolerate the consistency of toothpaste or for individuals who build up calculus easily, the caregiver can dip the toothbrush in an alcohol-free mouth- wash with fluoride and then brush normally. If all else fails, if the child lives in a fluoridated water community, the parent can always brush with tap water.
In communicating with caregivers, emphasize the key is to find adaptations that work for the caregiver and individual with SHCN, which can be challenging and take time. Also, keep encouraging caregivers to accomplish oral hygiene ev- ery day. For individuals living in a group facility, practitioners should write oral hygiene recommendations for the staff. If the individual is too tired or not tolerating toothbrushing at the traditional brushing times, find a time in their schedule when they will be more tolerant of it. Also, if time is limited due to cooperation, the caregiver can start on one arch for the first brushing and complete the other arch at the next brushing time so at least all teeth are brushed once a day.
Ultimately, by providing individuals with SHCN and their caregivers such simple tips, their everyday challenges can be overcome. A simple change, such as finding a tolerable toothpaste, can help these individuals infinitely and improve their overall experience with the provider and with their future oral health care. As many dental providers outside of pediatric dentists are not formally trained in caring for this population, by improving oral health and oral hygiene, this ultimately can reduce or even eliminate difficulties that these individuals can face later on. And if these individuals are tran- sitioned to a general dentist in adulthood, pediatric dentists can provide this information to their colleagues to help ease the transition. Individuals with SHCN and their caregivers have everyday hardships and hopefully with some encour- agement, information like what is given here, and a dental home, oral hygiene can be a manageable task for them and optimal oral health can be achieved.
Additional information, pictures, and videos of these recom- mendations can be found at the following websites:
  • dental-care-everyday.pdf