ORAL HEALTH

In twenty-first century America, a healthy smile is considered necessary for social mobility and acceptance, interpersonal relations, employability, and a good self-image.

Poor oral health may lead to pain and infection, absence from school or work, poor nutrition, poor general health, an inability to speak or eat properly, and even early death. Studies done in the late 1990s showed that poor oral health may also lead to low birth-weight babies, heart disease, and stroke. It is clear that oral diseases play a significant role in compromising health potential. Up until the late 1990s, when the new HIV medications became available, over 90 percent of persons with AIDS had HIV-related oral diseases.

MAJOR ORAL DISEASES

There are many different types of oral diseases, but they are generally differentiated as being of hard tissue or soft tissue origin. Hard-tissue oral diseases are those of the teeth, supporting bone, and jaw; whereas soft tissue diseases affect the tissues in and around the mouth, including the tongue, lips, cheek, gums, salivary glands, and roof and floor of the mouth. Some oral diseases may result in both hard and soft tissue disorders or conditions such as cleft palate or oral-facial injuries. The major oral diseases and conditions are:

• Dental caries (tooth decay, cavities)
• Periodontal disease (gum disease)
• Malocclusion (crooked teeth)
• Edentulism (complete tooth loss)
• Oral cancer
• Craniofacial birth defects such as cleft lip and cleft palate
• Soft tissue lesions
• Oral-facial injuries
• Temporomandibular dysfunction (TMD)

The prevalence of oral diseases varies due to differences in the host, agent, and environment. Some diseases have higher rates in certain population groups due to personal habits such as a sugarheavy diet or poor oral hygiene. Others may occur more frequently in individuals who put themselves at risk for injury by not wearing seatbelts or by playing contact sports without using proper mouth and head protection. Environmental and cultural factors may also affect the rates of oral diseases. For example, persons who live in a community in which the water supply is fluoridated would have much less tooth decay than those who live in a nonfluoridated community. Certain cultures, especially in developing countries, have diets almost completely devoid of refined foods that have high sugar content, and therefore have much less tooth decay compared to the average American. A 1997 report by the U.S. Department of Agriculture found that Americans consume an average of about 154 pounds of sugars a year (or 53 teaspoons a day) most of it in processed foods, drinks, and sweets. This was a 28 percent increase in added sugar or sweeteners since 1982. Tooth decay may be viewed as a disease of civilization.

A NEGLECTED EPIDEMIC

Oral diseases have been called a "neglected epidemic" because, while they affect almost the total population, oral health is not integrated into most health policies or programs. This is especially true in the United States, where, in the year 2000, there were 125 million Americans without dental insurance. In addition, many people who have dental insurance are underinsured. Under such conditions, people who are knowledgeable about oral health and have the resources to pay for it are much more likely to receive regular dental care than are the poorer members of society. This situation has resulted in major disparities in oral health status in the United States. Low-income children between ages two and five have almost five times more untreated dental disease than high-income children, and people without health insurance have four times the unmet dental needs of those with private insurance.

Vulnerable or high-risk population groups like children, the poor, the developmentally disabled, the homeless, homebound and elderly persons, persons with HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), and ethnic and cultural minorities are at greater risk for oral diseases, primarily because they do not have access to preventive services or treatment. In 2000, the first ever Surgeon General's report on oral health stressed the importance of oral health as part of total health as well as the need to reduce oral health disparities in the United States.

Although there has been much progress in the improvement of oral health, both nationally and internationally, oral diseases are still epidemic in the United States and many other countries. The nation's dental bill in the year 2000 was about $60.2 billion, or 4.6 percent of total health expenditures in the United States. In 1970, dental care accounted for 6.4 percent of total health expenditures. This 28 percent decrease is primarily due to the higher costs of hospitals and medical care.

PREVENTION

Prevention of dental disease may occur at the individual or community level. Prevention of disease at the community or population level is one of the foundations of public health practice. There are three levels of prevention. Primary prevention is aimed at preventing a disease before it occurs, through programs such as community water fluoridation, school dental sealant programs, and health education. Secondary prevention keeps an existing disease from becoming worse, and includes dental screenings for children and early detection of oral cancer in adults. Tertiary prevention consists of treatment to limit a disability or to help rehabilitate an individual after a disease has progressed beyond the secondary level. Examples of tertiary prevention include complex dental fillings, root canal treatment, and false teeth.

HEALTHY PEOPLE 2010

The United States has developed national health objectives with a focus on prevention. These objectives are renewed every ten years. This effort began with the 1979 report from the Surgeon General, Healthy People, and is spearheaded by the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services. The purpose of these national health objectives is to provide direction for the country in preventing major health problems in the United States. Each set of national health objectives, including the Healthy People 2010 objectives, contain components on oral health (see Table 1).

PUBLIC HEALTH DENTISTS

Of the nine recognized dental specialties, only dental public health has the potential to make a population-based impact on communities such as schools, neighborhoods, cities, states, or nations or on groups of individuals such as homeless children or persons with HIV. Dental public health is "the science and art of preventing and controlling dental disease and promoting dental health through organized community efforts. It is the form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis" (Journal of Public Health Dentistry, 46 no. 1). Most states in the United States have a dentist trained in public health in their state health department. The same is true in some major cities. The U.S. Department of Health and Human Services also has dentists trained in public health who work in administrative and policy-making roles.

A public health dentist is primarily involved with the three core functions of public health as defined by the Institute of Medicine: assessment, policy development, and assurance. Dental public health assessment might involve a statewide survey to determine the amount of tooth decay by age group, or a questionnaire to determine the barriers to dental care for the low-income elderly. Policy development could involve efforts to have preventive services included in a dental Medicaid program or to have a state dental practice act allow dental hygienists to work under general supervision in public schools. The assurance function might take the form of a program to provide dental care to homeless children, or to provide some other service that no one else is providing.

As of 2000, only 136 dentists out of 150,000 practicing dentists were board certified in dental public health by the American Board of Dental Public Health, and only about 1,500 dentists were working primarily in this field. Although the number of public health dentists is small, they are trained to work with a variety of health professionals and community groups to improve oral health. This would include, but not be limited to, public health dental hygienists, health educators, epidemiologists, nutritionists, nurses, academicians, researchers, and other health and human services personnel.

There are ten major areas of competencies that a dentist must attain to become board certified in dental public health. These ten competencies are: program planning; population-based prevention; developing, managing, and evaluating programs; needs assessment; communication; advocacy; study design; and critiquing the literature. Public health dentists can be contacted through the oral health program of local or state health departments, or through one of the ten regional offices of the U.S. Department of Health and Human Services.

TOOTH DECAY

Tooth decay, or dental caries, is the most common oral disease in the United States, if not the most common of all diseases. It is the primary cause of tooth loss; and may be considered a lifelong disease—18 percent of children aged 2 to 4 have had tooth decay in their primary teeth and 52 percent of those aged 6 to 8 have had tooth decay in their primary or permanent teeth; 78 percent of 17-year-olds have had tooth decay in their permanent teeth, with an average of seven affected tooth

Table 1

surfaces; 99 percent of adults aged 40 to 44 have had tooth decay in their permanent teeth, with an average of forty-five affected tooth surfaces; and 60 percent of persons over age 75 years of age have had tooth decay on the exposed roots of three of their teeth.

Tooth decay is an infectious disease. The percentage of people with this disease increases with age, and the severity of the disease once it occurs depends on whether or not one has had adequate fluoridation and dental treatment. Tooth decay is not self-limiting unless it is exposed to fluoride just as it is beginning and the demineralized tooth structure can remineralize. Demineralization is the dissolving of minerals such as calcium, carbonate, and phosphate in the tooth structure. Remineralization is enhanced by fluoride. Once tooth decay progresses beyond the tooth's ability to remineralize, mechanical intervention is needed by a dentist, who removes the decayed portion of the tooth and puts in a filling. When tooth decay is not treated it may result in an acute or chronic infection and severe pain, ultimately resulting in an abscess and/or cellulitis, which will then need to be treated with antibiotics, root canal treatment, or removal of the tooth. In the United States, more teeth are lost due to tooth decay than to any other disease.

Causes of Tooth Decay. Bacteria that produce tooth decay can be transferred from a mother to a child, even at an early age. When these bacteria have repeated contact with sugars or sticky sweets, they create an acid that demineralizes the surface or enamel of a susceptible tooth, eventually causing a cavity or tooth decay. The more access to sugars the bacteria have, the greater the likelihood of tooth decay occurring. Sticky sweets are more decay-producing than other types of sugary foods because they stay in the mouth longer. The bacterial mass that resides on the teeth is called dental plaque. Plaque may also, however, contain the minerals from demineralization, which may be available for remineralization.

Prevention of Tooth Decay. Tooth decay may be prevented on the individual level and at the community level. At the individual level, good oral hygiene—brushing with a fluoride toothpaste, sealants, and regular dental checkups—is of primary importance. Avoidance of excessive amounts of sugar and sweets, can also help prevent tooth decay. During the second half of the twentieth century, fluoride became an important tool in decay prevention. When fluoride is ingested, it goes through the body and becomes part of the tooth, resulting in a stronger tooth that is more resistant to tooth decay. When fluoride is placed on the teeth, it affects the tooth and plaque directly, preventing tooth decay. Fluoride is therefore added both to toothpaste and to community water supplies (see Figure 1).

Community water fluoridation consists of the adjustment of the fluoride level of a central water supply to a level that is optimal for oral health. The recommended level of fluoride for fluoridation in the United States varies from 0.7 to 1.2 parts per million, depending on a community's mean maximum daily air temperature over a five-year period. At the recommended level, the fluoride in water is odorless, colorless, and tasteless. In 1992, when the last national data was available, about 145 million Americans, or 62 percent of the population, were using fluoridated public-water supplies (see Figure 1).

Effective community prevention programs for tooth decay are considered in terms of effectiveness, cost, and practicality. Fluoridation is the most cost-effective. Fluoridation is considered one of the ten most significant public health measures of the twentieth century. Unfortunately, it has also been one of the more misunderstood public health measures, with some people at different times making claims such as it caused mongolism, pollution, sterility, or cancer. None of these allegations has ever been demonstrated by scientific studies. Most reputable national health organizations, such as the American Academy of Pediatrics, the American Dental Association, the American Medical Association, the American Public Health Association, and most other national health organizations, have supported or endorsed fluoridation for years. Salt fluoridation, which is not used in the United States, has been used as an alternative to water fluoridation in countries where central water supplies are not readily available.

Early Childhood Caries. The threat of tooth decay begins with the first appearance of teeth in a baby's mouth. The first teeth to appear are usually the two lower front teeth, which appear at about six months of age. All twenty primary, or baby, teeth usually erupt by two years of age. The permanent teeth begin erupting at six years of age, and with the eruption of the third molars (wisdom teeth), usually between eighteen and twenty-one years of age, all thirty-two permanent teeth are in place.

Early childhood caries (ECC) may be due to several factors, including the introduction of decay-producing bacteria into the child's mouth— usually transmitted from the mother or caused by poor feeding practices, various medical conditions, poor oral hygiene, and chronic malnutrition, which may also affect tooth development. ECC, also known as baby bottle tooth decay, or nursing tooth decay, occurs in the primary teeth of infants as young as nine months of age. When an infant sleeps with a baby bottle containing milk, infant formula, or sweetened liquids, there is a prolonged source of food for the decay-producing bacteria in the child's mouth. Among American Indians, as many as 53 percent of infants have this disease, and in inner city populations as many as 11 percent are affected. When early childhood caries is not treated and the disease is allowed to progress, severe pain or infection may result.

Root Surface Caries. This type of tooth decay usually occurs in older persons whose gums have receded exposing the roots of their teeth. As people retain their teeth for longer periods of time, this type of tooth decay becomes more frequent. Over 60 percent of seventy-five-year-olds who have teeth have root caries.

GUM (PERIODONTAL) DISEASE

Gum disease is the second most common reason for the loss of teeth. There are two major types of

Figure 1

gum disease: gingivitis, which is an inflammation or infection of the gums, and periodontitis, which is an inflammation or infection of the gums and the surrounding bone. Gingivitis may occur in adolescents or adults and is often self-healing once the area is properly cleaned. However, poor oral hygiene, stress, lack of sleep, or poor nutrition can all aggravate the condition and lead to an acute case of gingivitis, which can be very painful.

Gingivitis may lead to periodontitis in susceptible individuals who have risk factors such as bacterial plaque, calculus (calcified deposits around teeth), smoking, or systemic diseases. Periodontitis usually increases in severity with age. It is not selfhealing and requires mechanical intervention such as a deep scaling or surgery by a dentist. About 48 percent of adults aged thirty-five to forty-four have gingivitis, and 22 percent have destructive periodontal disease. Dentists who specialize in treating gum diseases are called periodontists.

The best way to prevent gum disease is with proper oral hygiene. This includes brushing the teeth properly with a fluoride toothpaste after breakfast and before going to bed, utilizing dental floss appropriately, and visiting a dentist or hygienist on a periodic basis for a professional cleaning. A combination of personal and professional prevention is very important, as there are no population-based preventive measures for gum disease. Good health habits, including proper nutrition and avoidance of tobacco products, is also important.

MALOCCLUSION

The permanent teeth may not erupt in their proper alignment, resulting in malocclusion, or crooked teeth. In its most severe form, called handicapping malocclusion, this condition can affect an individual's chewing ability. The main causes of malocclusion are a lack of space for the permanent teeth to erupt properly and the premature loss of the baby teeth, which usually guide the permanent teeth to their proper location, may also be a factor.

To prevent malocclusion due to premature loss of the primary teeth, space maintainers may be used to guide the teeth into proper alignment. Dentists who specialize in treating malocclusions are called orthodontists.

ORAL-FACIAL INJURIES

Most oral-facial injuries occur as a result of falls, automobile accidents, and sports. About 25 percent of Americans aged six to fifty have injured their upper or lower front teeth. Falls at work or at play are difficult to control. Some of them may be prevented, however, by self-discipline and by environmental controls such as railings, good lighting, smooth walkways, and proper injury-prevention education.

Oral and facial injuries are a frequent result of automobile accidents. Seatbelts, airbags, and safe driving techniques can greatly reduce the injuries. Sports-related oral-facial injuries may be prevented by wearing protective mouthguards and helmets. In competitive high school sports such as football, ice hockey, lacrosse, and soccer, mouthguards are required by many states. A school-based mouthguard program, in which a dentist fits each student athlete with a custom mouthguard, greatly improves the chances that the athletes will use the devices, which can otherwise be uncomfortable and inhibit breathing and talking.

ORAL CANCER

Oral and pharyngeal cancers occur primarily in individuals over fifty-five years of age, especially in those who smoke and drink heavily. About 30,000 Americans are diagnosed with oral cancer each year, and about 8,000 die from this disease. The earlier oral cancer is detected, the better it can be controlled. Only 7 percent of adults over the age of forty, however, have reported having an examination for oral cancer. Individuals who use spit tobacco beginning at an early age may have a greater risk for developing oral cancer and gum disease. Baseball players have traditionally used spit tobacco, luring younger children to also use it. According to the National Cancer Institute, over 15 percent of high school boys use spit tobacco. Marijuana use has also been linked to oral cancer. The incidence of oral cancer is two times greater in developing countries than in industrialized nations.

The best way to prevent oral cancer is not to smoke or to use spit tobacco, and, if one drinks, to drink in moderation. Adults, including those wearing dentures or false teeth, should have regular dental examinations that include an oral cancer screening. In 1994, the National Collegiate Athletic Association (NCAA) banned the use of spit tobacco and other tobacco products by student athletes and coaches during games and practices. Spit tobacco has also been banned in minor league baseball, and its use has been significantly reduced among major league players. Diets high in vitamin C, vegetables, and fruits may decrease the risk of oral cancer. A workshop to develop a national strategy to prevent and control oral cancer recommended a multifaceted approach that includes public advocacy, collaboration, public and professional education, and evaluation.

MOUTH ODOR

Mouth odors may be caused by poor oral hygiene or the foods that one eats. Mouth odors also occur when people have not eaten or had liquids for extended periods of time, such as in the morning upon waking. During sleep, there is a decrease in the flow of saliva, allowing bacteria to grow. Certain medications may also cause a condition known as xerostomia, or "dry mouth," which can lead to an increase in tooth decay over time. Over five hundred drugs and medicines list dry mouth as a potential side effect.

Proper oral hygiene and choice of foods can decrease or prevent mouth odors. In addition, sometimes bacteria accumulate on the tongue and brushing or scraping the back of the tongue periodically can help. Regular eating and drinking habits are also helpful. Dry mouth cannot be prevented, though water, ice chips, or sugarless gum may provide some relief.

CRANIOFACIAL DEFECTS

Approximately one to two in 1,000 children are born with a cleft lip or a cleft palate—two of the more common craniofacial defects. A cleft lip occurs when the lips of the developing fetus are not complete, resulting in a split in the child's lip. This usually occurs in the upper lip. A cleft palate is similar—the bone in the roof of the mouth is not fused properly and has an opening in it. Individuals born with cleft lips or palates should have corrective surgery and receive appropriate adjunctive therapy as needed, depending on the severity of the cleft.

There is no known way to prevent a cleft lip or palate. Proper prenatal care and food consumption during pregnancy may be important. Alcohol and tobacco consumption during pregnancy have been shown to increase the likelihood of cleft lip, so these substances should not be used by pregnant women.

TEMPOROMANDIBULAR DISORDERS

Temporomandibular (jaw) disorders (TMDs) are a group of conditions that affects the jaw joint. The lower jaw acts like a hinge with the upper jaw, and when the hinge joint is traumatized it may affect one's bite, cause pain in the chewing muscles, or cause pain or clicking in the joint located in front of the ears. This disorder affects twice as many women as men. Treatment varies depending on the severity of the problem. In many cases, the disorder dissipates by itself. This group of disorders is also referred to as myofacial pain-dysfunction syndrome of TMJ syndrome.

There is no simple way to prevent temporamandibular disorders. Avoiding trauma to the jaw or mouth may be helpful, and protective mouthguards should be used for contact sports.

Myron Allukian, Jr.

(see also: American Association of Public Health Dentistry; Baby Bottle Tooth Decay; Caries Prevention; Community Dental Preventive Programs; Community Water Fluoridation; Dental Fluorosis; Dental Sealants; Gingivitis; Healthy People 2010; Oral Cancer; Plaque )

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DENTAL CARE

A functional dentition—well-maintained and efficiently chewing teeth—is essential to good health and nutrition in the older adult. Demographic estimates indicate that by 2020, approximately 85 percent of adults over the age of sixty-five years will have retained some or all of their natural teeth (Douglass and Furino). By contrast, year 2020 projections suggest that nine million older adults will suffer from edentulism, the loss of all permanent teeth (Douglass and Furino). In general, individuals lose teeth as a result of trauma, tooth decay, or gum disease. The replacement of all permanent teeth is accomplished by the fabrication of complete dentures, prosthetic teeth that are fixed to plastic bases. The factors associated with tooth loss, the effect of total tooth loss, problems associated with complete dentures, and prevention of tooth loss are extremely relevant to the maintenance of good health and nutrition in the older adult.

Factors associated with tooth loss

Although trauma, tooth decay, gum disease, and aging are associated with tooth loss, most older adults in the United States lose teeth from gum disease, not through aging. Factors specifically related to the older adult that may facilitate tooth decay, gum disease, and tooth loss include lack of preventive dentistry in childhood and adolescence; limited access to dental care; lack of financial resources or dental insurance; low level of dental education; multiple medical conditions such as diabetes, osteoarthritis, stroke, Parkinson's disease, and cognitive disorders; and residence in a nursing home or long-term care facility.

Many preventive dental measures designed to maintain teeth for a lifetime were not available or accessible to today's older adults. Regular visits to the dentist, oral hygiene instruction, and the use of fluoride are commonplace today. These measures are the basis of dental awareness and education, and foster willingness to invest in programs that will prevent dental disease. Lack of dental insurance programs for the older adult and limited financial resources also may negatively impact oral health. Research with seventy-five-year-olds indicates, however, that age alone is not a good predictor of self-perceived dental needs and dental care utilization (Wilson and Branch). Rather than income or level of education, the presence of teeth appears to be the most powerful predictor of perceived dental need (Branch et al.).

The presence of multiple medical conditions in the older adult usually necessitates prescription drugs in addition to over-the-counter preparations the individual may already be taking. The potential for adverse drug interactions and side effects increases to 50 percent when five drugs are administered (Sloan). A common side effect of multiple medications in the older adult is xerostomia, or dry mouth (Paunovich et al.). Older adults with dry mouth often complain of mouth soreness, burning tongue, difficult chewing, problems with swallowing, and discomfort when wearing complete dentures (Felder et al.).

Research studies have proposed links between systemic illness and oral health status. Relevant to the issue of gum disease with resulting tooth loss are two studies that have investigated type II (adult onset) diabetes. One study suggests that individuals with poorly controlled blood sugar are at significantly greater risk for severe, progressive gum disease than are those with controlled blood sugar (Taylor et al.). A clinical study aimed at controlling blood sugar levels by treating gum disease has shown that standard gum disease treatments can result in significant blood sugar reductions (Grossi et al.). These studies are encouraging in view of the fact that type II diabetes and tooth loss to gum disease are common among older adults. Proper medical control of adult onset diabetes and proper dental control of gum disease help to prevent the loss of permanent teeth.

If permanent teeth are neglected as a result of poor, inadequate, or no oral hygiene procedures such as brushing and cleaning between the teeth, the oral health of the individual may be placed at risk. Bacteria within the mouth can initiate the disease processes responsible for tooth decay and gum disease. Daily removal of bacteria is essential to the health of the mouth. The frail older adult may not have enough strength to perform adequate oral hygiene. Individuals with cognitive impairment such as Alzheimer's disease often forget to perform basic oral hygiene. Older adults recovering from stroke may have paralysis of the dominant hand and be incapable of daily oral hygiene. Toothbrushing and other oral hygiene techniques can be very difficult to perform for older adults suffering from osteoarthritis, and Parkinson's disease. Hand and finger deformities common with osteoarthritis, and lack of muscle control in Parkinson's disease, may prevent these individuals from performing tasks often taken for granted.

Studies of residents of long-term care facilities and nursing homes suggest that they experience significant dental decay, bleeding of the gums, loose and uncomfortable complete dentures, and soft tissue sores attributed to wearing dentures (Weyant et al.; Kiyak et al.). In a study of 263 elderly subjects, 74 percent experienced difficult chewing, 72 percent reported oral discomfort, 54 percent reported functional dental handicaps, and 22 percent complained of oral pain (Lester et al.). Residents in assisted living facilities also appear to have more oral health problems.

Effect of total tooth loss

Removal of all teeth has immediate effects in the bone and soft tissue that formerly supported the teeth. These tissues undergo dramatic and irreversible changes. The bone connected to the roots of teeth (alveolar bone) anchors the teeth; as soon as the teeth are removed, it begins to dissolve and disappear. After removal of all permanent teeth, an individual is left with residual ridges of alveolar bone in the upper and lower jaws. The disappearance of these ridges (residual ridge resorption), has been described as chronic, progressive, irreversible, and disabling (Atwood). Not only does the bone resorb and shrink in size and shape, but the soft tissues over the bone collapse. The definitive scientific investigation of alveolar bone resorption concluded that the process is very aggressive in the first year, occurs four times more extensively in the lower jaw than the upper jaw, and may result in one centimeter of vertical bone loss in the lower jaw after twenty-five years of wearing complete dentures (Tallgren). The resorption process compromises successful denture wearing.

The loss of all teeth creates other problems. An individual loses essential support for the muscles of facial expression. Typically, one observes sunken cheeks, unsupported lips, and a facial profile on which the nose and chin appear to be too close together. The profile is altered because teeth support the jaws and the vertical dimension of the face; therefore, in the absence of teeth, the facial structures collapse upon themselves. Because front teeth help to pronounce many sounds and words, speech is affected when the teeth are removed. Functionally, most older adults attempt to wear complete dentures in order to chew food effectively. In addition, many adults will not venture into a public or social setting without teeth. Consequently, it is not surprising that edentulism has been associated with a reduction in quality of life, self-image, and daily functioning (Gift and Redford).

Problems with complete dentures

Although teeth are important to proper speech and to a pleasing smile, chewing food is the main function of a complete and healthy dentition. In the absence of all permanent teeth, a dental professional may be asked to make upper and lower complete dentures. Complete dentures consist of specially manufactured plastic, prosthetic teeth that are processed to high-impact plastic bases. The process of complete denture fabrication consists of five steps. The first two are patient assessment and making impressions or molds of the residual alveolar ridges. These steps result in upper and lower casts of the ridges upon which the complete dentures are constructed. At the third step, the patient's correct occlusion or bite is recorded. Prosthetic teeth are chosen to satisfy the patient's aesthetic and functional needs. At the fourth appointment, the patient previews the complete dentures before the dental laboratory processes the prosthetic teeth to the base. At the final appointment, the patient receives the complete dentures and begins to function with them.

In the process of complete denture fabrication, three areas can be the source of frustration and failure for both the dental professional and the patient. First, the dental professional must communicate effectively with the patient, and vice versa. Promises made by the dental professional may be untrue for a specific patient. Such promises include the following: Patients adapt easily to complete dentures; complete dentures are as functional and efficient as natural teeth; and dentures are comfortable to wear. Likewise, patients whose expectations of complete dentures equal or exceed those of natural teeth need to be educated to the contrary. Second, making the impression is critical. Complete dentures that are constructed on inadequate casts from poor impressions are too small and lack essential features for retention and stability within the mouth. A functionally stable and retentive denture must utilize all available support tissues within the mouth. A shortcut in this step may lead to an unstable, painful denture. Third, a proper occlusion or bite is essential to acceptable functioning and comfortable wearing. When the occlusion is disregarded, complete dentures may create soreness in multiple areas of the mouth. Neglect in any or all of these critical areas results in unhappy denture wearers and frustrated dental professionals.

It is important to note that medically compromised patients who suffer from xerostomia may have difficulty adjusting to and functioning with complete dentures. Saliva is responsible not only for the retention of complete dentures but also, in part, for a comfortable fit. With a substantial lack of saliva, the denture wearer's ability to function comfortably is seriously compromised.

A traditional belief is that wearers of complete dentures alter their food choices because of compromised chewing and, therefore, are not well nourished. The chewing efficiency of complete dentures and their impact on nutrition have been studied extensively. A study of 1,106 individuals of differing ages and with various numbers of natural teeth clearly demonstrated that number of teeth, not age, best explained chewing ability (Carlsson). Refitting old dentures or fabrication of new dentures should improve chewing efficiency for denture wearers; however, none to only slight chewing improvement was found when individuals were evaluated for eighteen months (Carlsson). Another study reported that, compared to those with natural teeth, subjects wearing complete dentures required greater chewing time and more chewing strokes to complete chewing tests (Wayler and Chauncey). In addition, wearers of complete dentures selected food largely on the basis of texture and tactile characteristics, preferring soft, easy-to-chew foods (Wayler and Chauncey). Investigators in a Veterans Administration study concluded that individuals wearing at least one complete denture may have self-imposed dietary restrictions that could compromise nutritional well-being (Chauncey et al.). Functionally, the maximum biting force that complete denture wearers can demonstrate is approximately 33 percent of the force generated with natural teeth (Carlsson). Thus, the traditional belief that denture wearers may have compromised nutrition appears to have been validated by research. The most carefully fabricated complete dentures, made by the most experienced dental professional, and worn by the most adaptable, proficient older adult can never deliver the performance of well-maintained natural dentition.

Prevention of tooth loss

An important strategy for maintaining a healthy, natural dentition is regular dental visits with oral hygiene instruction. Depending upon the medical and dental condition of the individual, older adults should visit the dentist every three to six months. This frequency enables the dentist or dental hygienist to diagnose potential tooth decay and gum disease before it can become a major problem. Because both decay and gum disease are caused by accumulations of mouth bacteria (dental plaque), proper oral hygiene instruction is crucial.

Aimed at preventing both gum disease and tooth decay, oral hygiene begins with mechanical plaque removal. This is best accomplished with brushing the teeth and cleaning between the teeth. Dental floss, between-the-teeth brushes, and toothpicks can be used to remove plaque from between the teeth. Daily, effective removal of dental plaque is critical in preventing dental disease. For those with physical handicaps, a caretaker may be required to assist in daily oral hygiene.

The role of saliva in maintaining dental health is crucial. Saliva is essential in controlling and clearing bacteria from the mouth. For older adults who suffer from dry mouth, the protective action of saliva is compromised. Regimens to replace or stimulate salivary flow include sips of water, chewing sugarless gum, and using sugarless mints. Sugar-free gums and mints are crucial for individuals with natural teeth, because disease-producing bacteria readily metabolize sugar to end products that cause tissue destruction.

Another strategy to control the levels of mouth bacteria is the use of antibacterial mouth rinses. Numerous over-the-counter preparations are available, and one phenolic rinse has been shown to significantly reduce oral bacteria for short periods of time (Moran et al.). If indicated, the dentist may prescribe a more powerful oral rinse, chlorhexidine. Chlorhexidine rinse at 0.12 percent strength is the most effective, sustained antibacterial agent available (Persson et al.).

While saliva and antibacterial rinses target both gum disease and tooth decay, fluoride preparations are specifically used to fortify and strengthen tooth structure, a process called remineralization. Older adults should be encouraged to use fluoride-containing toothpaste. Remineralization with fluoride toothpaste has been well documented (Wefel et al.).

Over-the-counter 0.05 percent fluoride rinses have been shown to reduce tooth decay and remineralize tooth structure (Ripa et al.). Fluoride gels, applied at home or in the dental office, have been shown to prevent decay and significantly remineralize tooth structure in extremely susceptible cancer patients (Dreizen et al.; Katz).

The loss of all permanent teeth and the wearing of complete dentures is not without serious functional and social limitations. Research indicates that a healthy, functional, natural dentition is important to good general health, adequate nutrition, and a sense of well-being in the older adult. The maintenance of a permanent, natural dentition can be accomplished through tested and verified strategies that are available from the dental professional.

Jeffrey D. Astroth

See also Nutrition.

BIBLIOGRAPHY

Atwood, D. A. "The Reduction of Residual Ridges. A Major Oral Disease Entity." Journal of Prosthetic Dentistry 26 (1971): 266–279.

Branch, L. G.; Antczak, A. A.; and Stason, W. B. "Toward Understanding the Use of Dental Services by the Elderly." Special Care in Dentistry 6 (1986): 38–41.

Carlsson, G. E. "Masticatory Efficiency: The Effect of Age, the Loss of Teeth and Prosthetic Rehabilitation." International Dental Journal 34 (1984): 93–97.

Chauncey, H. H.; Muench, M. E.; Kapur, K. K.; and Wayler, A. H. "The Effect of the Loss of Teeth on Diet and Nutrition." International Dental Journal 34 (1984): 98–104.

Douglass, C. W., and Furino, A. "Balancing Dental Services Requirements and Supplies: Epidemiologic and Demographic Evidence." Journal of the American Dental Association 121 (1990): 587–592.

Dreizen, S.; Brown, L. R.; Daly, T. E.; and Drane, J. B. "Prevention of Xerostomia-Related Dental Caries in Irradiated Cancer Patients." Journal of Dental Research 56 (1977): 99–104.

Felder, R. S.; Millar, S. B.; and Henry, R. H. "Oral Manifestations of Drug Therapy." Special Care in Dentistry 8 (1988): 119–124.

Gift, H. C., and Redford, M. "Oral Health and Quality of Life." Clinical Geriatric Medicine 8 (1992): 673–683.

Grossi, S. G.; Skrepcinski, F. B.; DeCaro, T.; et al. "Treatment of Periodontal Disease in Diabetes Reduced Glycated Hemoglobin." Journal of Periodontology 68 (1997): 713–719.

Katz, S. "The Use of Fluoride and Chlorhexidine for the Prevention of Radiation Caries." Journal of the American Dental Association 104 (1982): 164–170.

Kiyak, H. A.; Grayston, M. N.; and Crinean, C. L. "Oral Health Problems and Needs of Nursing Home Residents." Community Dentistry and Oral Epidemiology 21 (1993): 49–52.

Lester, V.; Ashley, F. P.; and Gibbons, D. E. "The Relationship Between Socio-dental Indices of Handicap, Felt Need for Dental Treatment and Dental State in a Group of Frail and Functionally Dependent Older Adults." Community Dentistry and Oral Epidemiology 26 (1998): 155–159.

Moran, J.; Addy, M.; Wade, W.; et al. "The Effect of Oxidizing Mouthrinses Compared with Chlorhexidine on Salivary Bacterial Counts and Plaque Regrowth." Journal of Clinical Periodontology 22 (1995): 750–755.

Paunovich, E. D.; Sadowsky, J. M.; and Carter, P. "The Most Frequently Prescribed Medications in the Elderly and Their Impact on Dental Treatment." In The Dental Clinics of North America, vol. 41, no. 4. Philadelphia: W. B. Saunders, 1987. Page 702.

Persson, R. E.; Truelove, E. L.; LeResche, L.; and Robinovitch, M. R. "Therapeutic Effects of Daily or Weekly Chlorhexidine Rinsing on Oral Health of a Geriatric Population." Oral Surgery, Oral Medicine, Oral Pathology 72 (1991): 184–191.

Ripa, L. W.; Leske, G. S.; Forte, F.; and Varma, A. "Effect of a 0.05% Neutral NaF Mouthrinse on Coronal and Root Caries of Adults." Gerodontology 6 (1987): 131–136.

Sloan, R. W. "Drug Interactions." In Practical Geriatric Therapeutics. Oradell, N.J.: Medical Economics, 1986. Page 39.

Tallgren, A. "The Continuing Reduction of the Residual Alveolar Ridges in Complete Denture Wearers: A Mixed Longitudinal Study Covering 25 Years." Journal of Prosthetic Dentistry 27 (1972): 120–132.

Taylor, G. W.; Burt, B. A.; Becker, M. P.; et al. "Severe Periodontitis and Risk for Poor Glycemic Control in Patients with Non-Insulin-Dependent Diabetes Mellitus." Journal of Periodontology 67 (1996): 1085–1093.

Wayler, A. H., and Chauncey, H. H. "Impact of Complete Dentures and Impaired Natural Dentition on Masticatory Performance and Food Choice in Healthy Aging Men." Journal of Prosthetic Dentistry 49 (1983): 427–432.

Wefel, J. S.; Jensen, M. E.; Triolo, P. T.; et al. "De/Remineralization from Sodium Fluoride Dentifrices." American Journal of Dentistry 8 (1995): 217–220.

Weyant, R. J.; Jones, J. A.; Hobbins, M.; et al. "Oral Health Status of a Long-Term Care, Veteran Population." Community Dentistry and Oral Epidemiology 21 (1993): 227–233.

Wilson, A. A., and Branch, L. G. "Factors Affecting Dental Utilization of Elders Aged 75 Years or Older." Journal of Dental Education 50 (1986): 673–677.

Oral hygiene

Definition

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

Purpose

The purpose of oral hygiene is to prevent the buildup of plaque, the sticky film of bacteria and food that forms on the teeth. Plaque adheres to the crevices and fissures of the teeth and generates acids that, when not removed on a regular basis, slowly eat away, or decay, the protective enamel surface of the teeth, causing holes (cavities) to form. Plaque also irritates gums and can lead to gum disease, periodontal disease , and tooth loss. Brushing and flossing removes plaque from teeth, and antiseptic mouthwashes kill some of the bacteria that help form plaque. Fluoride, found in toothpaste, drinking water, or dental treatments, also helps to protect teeth by binding with enamel to make it stronger. In addition to such daily oral care, regular visits to the dentist promote oral health. Preventative services that the dentist can perform include fluoride treatments, sealant application, and scaling (scraping off the hardened plaque, called tartar). The dentist can also perform such diagnostic services as x-ray imaging and such treatments as filling cavities.

Description

The Centers for Disease Control and Prevention report that dental caries are perhaps the most prevalent of infectious diseases in children. More than 40 percent of all children have cavities by the time they reach kindergarten. It is, therefore, imperative that all parents learn the importance of early oral care and that they teach their children proper oral hygiene.

Good oral hygiene should start at the very beginning of a child's life. Even before his or her first teeth emerge, certain factors can affect their future appearance and health. Pregnant and nursing mothers should be careful about using medications, as some, like the antibiotic tetracycline, can cause tooth discoloration. Even before infants have teeth, they have special oral hygiene needs about which all parents should be aware. These include making certain the child receives adequate fluoride and guarding against baby bottle decay.

Fluoride in infancy

Fluoride is beneficial for babies even before their teeth erupt. It makes the tooth enamel stronger as the teeth are developing. In most municipal water supplies, the correct amount of fluoride is added for proper tooth development. If the water supply does not contain enough fluoride or if bottled water is used for drinking and cooking, the doctor or dentist should be informed. They may prescribe fluoride supplements for the baby.

Baby bottle decay

Baby bottle decay is caused by recurring exposure over time to sugary liquids. These include milk, formula, and fruit juices. These liquids pool for prolonged periods of time as the child sleeps. This exposure can lead to cavities forming, especially in the upper and lower front teeth. For this reason, children should not be allowed to fall asleep with a bottle of juice or milk in their mouths. An alternative is to give the child a bottle filled with water or a pacifier recommended by the dentist. Even breast-fed children are at risk. They should have their gums and teeth wiped with a clean, damp washcloth or gauze pad following each feeding.

Baby teeth, also known as primary teeth, are just as important as permanent teeth. They help the child to bite and chew food, help them speak correctly, save space for the child's permanent teeth, and help guide the permanent teeth into place. That is why it is so important to initiate a program of good oral hygiene for children early on.

Brushing

Once a baby has four teeth in a row, either on top or on the bottom, parents should begin using a toothbrush two times a day. When choosing a toothbrush, make sure the bristles are soft, polished, and made of nylon. Parents should administer only a pea-size amount of fluoride toothpaste that is made especially for children. Children tend to swallow, instead of spit out, toothpaste. If the child does not like the flavor of the toothpaste, using water alone is acceptable. Parents should also continue to wipe the toothless gum areas with a washcloth or gauze.

As the child gets older, parents should demonstrate proper brushing techniques. These include brushing the inside surface of each tooth first, where plaque tends to accumulate most. Then they should clean the outer surfaces of each tooth, angling the brush along the outer gum line. Next, they should brush the chewing surface of each tooth, then using the tip of the brush, clean behind each front tooth. They should use a gentle, back and forth motion when brushing and finish by brushing the tongue.

Children will, at some point, decide they would like to try brushing their teeth themselves. This is fine and should be encouraged, but parents should remain in charge of keeping children's teeth clean until they are between six to eight years old. Children do not have the dexterity or coordination to perform brushing well until this time. Even then, it is important that parents inspect their children's teeth each time they brush. They should pay special attention to the molars, as these teeth have lots of tiny grooves and crevices where food particles can hide.

Good oral hygiene remains important as children grow into adolescence . In fact, adolescence can often be a time when cavities and periodontal disease happen more frequently. This higher rate is usually caused by an increased intake of junk food and sugary foods such as soft drinks, as well as inattention to oral hygiene procedures. Add to that the fact that many older children and teens wear braces, making the cleaning of teeth even more challenging. Parents should talk to their children about how important good oral hygiene is in preventing not only cavities, but teeth stains, bad breath, and an assortment of other dental problems.

Flossing

Flossing once a day helps to prevent gum disease by removing food particles and plaque at and below the gum line, as well as between teeth. Parents do not need to initiate flossing until the child has teeth that touch each other, which normally occurs in the molar areas first. Parents should continue to floss their child's teeth until they are six or seven years old. They should continue to monitor the child's techniques and consistency thereafter.

Proper flossing technique is essential in removing as much plaque as possible in a safe manner. The following procedure is recommended by dental hygienists. Wind 18 inches (45 cm) of dental floss around the middle fingers of each hand. Pinch the floss between the thumbs and index fingers, leaving about 1–2 inches (3–5 cm) length in between. Use the thumbs to direct the floss between the upper teeth. Try to keep the floss taut between the fingers. Use the index fingers to guide floss between lower teeth. Gently guide the floss between the teeth by using a zig-zag motion. Contour the floss around the side of each tooth. Slide the dental floss up and down against the tooth surface and under the gum line. Floss each tooth thoroughly with a clean section of floss.

Dental floss comes in many varieties (waxed, unwaxed, flavored, tape) and may be chosen based on personal preference. For those who have difficulty handling floss, floss holders and other types of interdental (between the teeth) cleaning aids are available. Some floss holders have animal and cartoon characters on them, which might make flossing more appealing to a child.

Precautions

It is important that younger children only use a very small amount of fluoridated toothpaste since using too much fluoride can be toxic to infants. Though brushing and flossing are important, neither should be performed too vigorously. The rough mechanical action may irritate or damage oral tissues. Parents should change their child's toothbrush three to four times a year and after every illness to avoid bacteria and germs.

Another factor that may affect a child's oral health is the increasingly popular practice among adolescents of oral piercings involving the tongue, lips, and cheeks. These piercings have been associated with infections, tooth fractures, periodontal disease, and nerve damage. Some life-threatening complications have occurred, including bleeding and airway obstruction. The American Academy of Pediatric Dentistry strongly opposes the practice of oral piercings.

Risks

The primary risks arise from a lack of proper oral hygiene practices. These major oral health problems are plaque, tartar, gingivitis, periodontitis, and tooth decay.

Parental concerns

Parents play an important role in both modeling and teaching good oral hygiene. Parents can make sure their child sees a dentist before the age of two. This can be a frightening experience for some children, but if parents exhibit a positive attitude, most children become comfortable with dentist visits. Children who learn proper oral care at a young age benefit from those good habits for the rest of their lives.

KEY TERMS

Calculus —Plural, calculi. Any type of hard concretion (stone) in the body, but usually found in the gallbladder, pancreas, and kidneys. They are formed by the accumulation of excess mineral salts and other organic material such as blood or mucous. Calculi (pl.) can cause problems by lodging in and obstructing the proper flow of fluids, such as bile to the intestines or urine to the bladder. In dentistry, calculus refers to a hardened yellow or brown mineral deposit from unremoved plaque, also called tartar.

Cavity —A hole or weak spot in the tooth surface caused by decay.

Gingivitis —Inflammation of the gums in which the margins of the gums near the teeth are red, puffy, and bleeding. It is most often due to poor dental hygiene.

Pediatric dentistry —The dental specialty concerned with the dental treatment of children and adolescents.

Plaque —A deposit, usually of fatty material, on the inside wall of a blood vessel. Also refers to a small, round demyelinated area that develops in the brain and spinal cord of an individual with multiple sclerosis.

Resources

BOOKS

Sutton, Amy. Dental Care and Oral Health Sourcebook: Basic Consumer Health Information about Dental Care . . . Detroit, MI: Omnigraphics, 2003.

Vogel, Elizabeth. Brushing My Teeth. New York: Rosen Publishing Group, 2001.

PERIODICALS

Garwood, Derrick. "Oral Hygiene." The Pharmaceutical Journal 270 (May 3, 2003): 619–21.

ORGANIZATIONS

American Academy of Pediatric Dentistry. 211 East Chicago Avenue, Suite 700, Chicago, IL 60611. Web site: <www.aapd.org>.

American Dental Hygienists' Association. 444 North Michigan Avenue, Suite 3400, Chicago, IL 60611. Web site: <www.adha.org>.

WEB SITES

"Oral Health Resources." Centers for Disease Control and Prevention. Available online at <www.cdc.gov/OralHealth/index.htm> (accessed October 26, 2004).

Deanna M. Swartout-Corbeil, RN Bethany Thivierge

Oral Hygiene

Definition

Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease.

Purpose

The purpose of oral hygiene is to prevent the build-up of plaque, the sticky film of bacteria and food that forms on the teeth. Plaque adheres to the crevices and fissures of the teeth and generates acids that, when not removed on a regular basis, slowly eat away, or decay, the protective enamel surface of the teeth, causing holes (cavities) to form. Plaque also irritates gums and can lead to gum disease (periodontal disease ) and tooth loss. Toothbrushing and flossing remove plaque from teeth, and antiseptic mouthwashes kill some of the bacteria that help form plaque. Fluoride—in toothpaste, drinking water, or dental treatments—also helps to protect teeth by binding with enamel to make it stronger. In addition to such daily oral care, regular visits to the dentist promote oral health. Preventative services that he or she can perform include fluoride treatments, sealant application, and scaling (scraping off the hardened plaque, called tartar). The dentist can also perform such diagnostic services as x-ray imaging and oral cancer screening as well as such treatment services as fillings, crowns, and bridges.

Precautions

Maintaining oral hygiene should be a lifelong habit. An infant's gums and, later, teeth should be kept clean by wiping them with a moist cloth or a soft toothbrush. However, only a very small amount (the size of a pea) of toothpaste containing fluoride should be used since too much fluoride may be toxic to infants.

An adult who has partial or full dentures should also maintain good oral hygiene. Bridges and dentures must be kept clean to prevent gum disease. Dentures should be relined and adjusted by a dentist as necessary to maintain proper fit so the gums do not become red, swollen, and tender.

Brushing and flossing should be performed thoroughly but not too vigorously. Rough mechanical action may irritate or damage sensitive oral tissues. Sore or bleeding gums may be experienced for the first few days after flossing is begun. However, bleeding continuing beyond one week should be brought to the attention of a dentist. As a general rule, any sore or abnormal condition that does not disappear after 10 days should be examined by a dentist.

Description

Brushing

Brushing should be performed with a toothbrush and a fluoride toothpaste at least twice a day and preferably after every meal and snack. Effective brushing must clean each outer tooth surface, inner tooth surface, and the flat chewing surfaces of the back teeth. To clean the outer and inner surfaces, the toothbrush should be held at a 45-degree angle against the gums and moved back and forth in short strokes (no more than one toothwidth distance). To clean the inside surfaces of the front teeth, the toothbrush should be held vertically and the bristles at the tip (called the toe of the brush) moved gently up and down against each tooth. To clean the chewing surfaces of the large back teeth, the brush should be held flat and moved back and forth. Finally, the tongue should also be brushed using a back-to-front sweeping motion to remove food particles and bacteria that may sour the breath.

Toothbrushes wear out and should be replaced every three months. Consumers should look for tooth-brushes with soft, nylon, rounded bristles in a size and shape that allows them to reach all tooth surfaces easily.

Holding a toothbrush may be difficult for people with limited use of their hands. The toothbrush handle may be modified by inserting it into a rubber ball for easier gripping.

Flossing

Flossing once a day helps prevent gum disease by removing food particles and plaque at and below the gumline as well as between teeth. To begin, most of an 18-in (45-cm) strand of floss is wrapped around the third finger of one hand. A 1-in (2.5-cm) section is then grasped firmly between the thumb and forefinger of each hand. The floss is eased between two teeth and worked gently up and down several times with a rubbing motion. At the gumline, the floss is curved first around one tooth and then the other with gentle sliding into the space between the tooth and gum. After each tooth contact is cleaned, a fresh section of floss is unwrapped from one hand as the used section of floss is wrapped around the third finger of the opposite hand. Flossing proceeds between all teeth and behind the last teeth. Flossing should also be performed around the abutment (support) teeth of a bridge and under any artificial teeth using a device called a floss threader.

Dental floss comes in many varieties (waxed, unwaxed, flavored, tape) and may be chosen on personal preference. For people who have difficulty handling floss, floss holders and other types of interdental (between the teeth) cleaning aids, such as brushes and picks, are available.

Risks

Negative consequences arise from improper or infrequent brushing and flossing. The five major oral health problems are plaque, tartar, gingivitis, periodontitis, and tooth decay.

Plaque is a soft, sticky, colorless bacterial film that grows on the hard, rough surfaces of teeth. These bacteria use the sugar and starch from food particles in the mouth to produce acid. Left to accumulate, this acid destroys the outer enamel of the tooth, irritates the gums to the point of bleeding, and produces foul breath. Plaque starts forming again on teeth four to 12 hours after brushing, so brushing a minimum of twice a day is necessary for adequate oral hygiene.

When plaque is not regularly removed by brushing and flossing, it hardens into a yellow or brown mineral deposit called tartar or calculus. This formation is crusty and provides additional rough surfaces for the growth of plaque. When tartar forms below the gumline, it can lead to periodontal (gum) disease.

Gingivitis is an early form of periodontal disease, characterized by inflammation of the gums with painless bleeding during brushing and flossing. This common condition is reversible with proper dental care but if left untreated, it will progress into a more serious periodontal disease, periodontitis.

Periodontitis is a gum disease that destroys the structures supporting the teeth, including bone. Without support, the teeth will loosen and may fall out or have to be removed. To diagnose periodontitis, a dentist looks for gums that are red, swollen, bleeding, and shrinking away from the teeth, leaving widening spaces between teeth and exposed root surfaces vulnerable to decay.

Tooth decay, also called dental caries or cavities, is a common dental problem that results when the acid produced by plaque bacteria destroys the outer surface of a tooth. A dentist will remove the decay and fill the cavity with an appropriate dental material to restore and protect the tooth; left untreated, the decay will expand, destroying the entire tooth and causing significant pain.

Normal results

With proper brushing and flossing, oral hygiene may be maintained and oral health problems may be avoided. Older adults may no longer assume that they will lose all of their teeth in their lifetime. Regular oral care preserves speech and eating functions, thus prolonging the quality of life.

Resources

ORGANIZATIONS

American Dental Association. 211 E. Chicago Ave., Chicago, IL 60611. (312) 440-2500. 〈http://www.ada.org〉.

American Dental Hygienists' Association. 444 North Michigan Ave., Chicago, IL 60611. (800) 847-6718.

OTHER

Healthtouch Online Page. 〈http://www.healthtouch.com〉.

KEY TERMS

Calculus— A hardened yellow or brown mineral deposit from unremoved plaque; also called tartar.

Cavity— A hole or weak spot in the tooth surface caused by decay.

Gingivitis— Inflammation of the gums, seen as painless bleeding during brushing and flossing.

Interdental— Between the teeth.

Periodontal— Pertaining to the gums.

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

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

Tartar— A hardened yellow or brown mineral deposit from unremoved plaque; also called calculus.

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 odorcausing 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, tooth-brush 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.

KEY TERMS

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.

Resources

PERIODICALS

Mantokoudis, D., et al. "Comparison of the Clinical Effects and Gingival Abrasion Aspects of Manual and Electric Toothbrushes." Journal of Clinical Periodontology (January 2001): 65-72.

ORGANIZATIONS

American Dental Association. 211 East Chicago Ave., Chicago, IL 60611. (312) 440-2500. 〈http://www.ada.org〉.

American Dental Hygienists' Association. 444 N. Michigan Ave., Suite 3400, Chicago, IL 60611. (800) 243-2342. 〈http://www.adha.org〉.

OTHER

"Gum Disease (Periodontal Disease)." ADA.org: The Public. 〈http://www.ada.org/public/index.asp〉.

Healthtouch Online. Medical Strategies Inc. 〈http://www.healthtouch.com〉.

"Oral Health Information." ADHA Online. 〈http://www.adha.org〉.