In safe hands
This article explores the oral health challenges facing patients who have limited dexterity, and how to help them bridge that gap. Brought to you by Johnson & Johnson Ltd, the makers of Listerine.
According to an analysis of living conditions in Europe, disability in Europe will affect a quarter of women and one in six men aged 65 by 2047.
One common condition that causes pain and inflammation in joints, making movement more difficult than usual, is arthritis. It affects more than 10 million people in the UK.
Disabilities commonly affect joints in the hands. This may also inhibit oral health self-care: ‘…a strong positive relationship between poor oral hygiene and individual dexterity, in elderly individuals’ (Barouch, Al Asaad and Alhareky, 2019).
On this issue, Barouch and colleagues (2019) consequently wrote: ‘Those who are not dexterous may be at a disadvantage as they are unable to perform some manoeuvres which could have a positive effect on the oral hygiene status’ (Barouch, Al Asaad and Alhareky, 2019).
Manoeuvres that may prove difficult for people with limited dexterity include (Barouch, Al Asaad and Alhareky, 2019):
- Holding a toothbrush properly
- Controlling the force applied by the toothbrush onto the tooth surface
- Targeting and reaching the area requiring cleaning
- Movement of the toothbrush
- Speed of brushing
- Reaction time to recognition of discomfort
- Hand and arm stability
- Finger co-ordination
- Wrist flexion action
Providing extra help
As stated by Dougall and Fiske (2008), dental patients with disabilities may need extra help to achieve and maintain a good level of oral health. Indeed, the first step is to create a tailored routine for an oral hygiene at-home regimen. This includes adaptations to minimise the effects of any impairment.
The toothbrush is the most commonly used tool to remove dental plaque. Therefore a number of adaptations help manage tooth brushing for those who might otherwise experience a barrier to this important element of oral hygiene (Dougall and Fiske, 2008).
For example, if a patient’s main challenge is overcoming grasp, manipulation or control issues, an enlarged or elongated handle might prove beneficial, as might a hand attachment. The aim is therefore to provide a more stable grip for the patient. And to find a handle shape that enables them to sense how the brush needs to be manipulated within the oral cavity. Therefore achieving an adequate level of tooth brushing (Dougall and Fiske, 2008).
Opening a tube of toothpaste can also be difficult. However toothpaste pumps and dispensers are easier to manage than a tube with a cap. In addition, there are toothpaste dispensers available that mete out an appropriate amount of toothpaste when its lever is pressed (Dougall and Fiske, 2008).
The next step in the mechanical cleaning process is that of interdental care. Conventional flossing can be difficult to perform effectively, but single-use or self-threading floss holders may prove easier to use (Dougall and Fiske, 2008).
An adjunctive solution
Barnett (2006) suggested the ‘vast majority’ of people are unable to maintain a good level of oral health using mechanical means alone, and that this gap in preventive care provides: ‘[…] a clear rationale for incorporating effective antimicrobial measures, such as use of an antimicrobial mouthrinse, into daily oral hygiene regimens.’
Given that personal oral hygiene can be even more challenging for patients with limited dexterity, using an adjunct to mechanical cleaning may prove helpful (Walls and Meurman, 2012).
Boyle and colleagues (2014) investigated mouthwash use and the prevention of plaque, gingivitis and caries. They explored the efficacy of chemotherapeutic ingredients including chlorhexidine, essential oils, cetylpyridinium and triclosan.
They concluded that over a period of less than three months, mouthwashes containing chlorhexidine were the most effective of the ingredients considered, resulting in a reduction of dental plaque.
When used for six months or longer, essential oil-containing mouthwash equalled or exceeded the effect of chlorhexidine in controlling plaque as an adjunct to mechanical cleaning.
They further found that cetylpyridinium or triclosan may be effective, but less so than mouthwash containing chlorhexidine or essential oils.
Simple strategies for success
Offering a practical overview of the situation, Preston (2012) wrote: ‘Elderly patients often have a decreased ability to implement satisfactory oral and denture hygiene. This can be for a variety of reasons. Perhaps the most obvious reason is when a patient suffers from rheumatoid arthritis affecting the hands. In these cases, the patient’s ability to complete even simple oral hygiene practices is almost impossible. For such patients, simple strategies, such as adding silicone “handles” to a manual toothbrush can help. In addition, chemical means of dental plaque control can be advised to supplement physical methods of plaque removal.’
He continued: ‘When advising elderly patients with regards to their oral hygiene, therefore, such factors should be taken into account and unrealistic expectations on such oral hygiene standards should not be made. This is especially true of interdental plaque control, which can be particularly difficult to execute for an elderly patient with rheumatoid arthritis.’
Irrespective of age, there are a growing number of people living with ‘long-term disabling conditions’. To serve these patients effectively, according to Scambler and Curtis (2019), the need to: ‘…identify and remove barriers remains paramount to the provision of good quality, equitable dental care.’
Barnett ML (2006) The rationale for the daily use of an antimicrobial mouthrinse. JADA 137: 16S-21S
Barouch K, Al Asaad N and Alhareky M (2019) Clinical relevance of dexterity in oral hygiene. Br Dent J 225(5): 354-7
Boyle P, Koechlin A and Autier P (2014) Mouthwash use and the prevention of plaque, gingivitis and caries. Oral Dis 20 (Supp1): 1-68
Dougall A and Fiske J (2008) Access to special care dentistry, part 4. Education. Br Dent J 205(3): 119-30
Preston AJ (2012) Dental management of the elderly patient. Dent Update 39: 141-4
Scambler S, Curtis SA (2019) Contextualising disability and dentistry: challenging perceptions and removing barriers. Br Dent J 227(1): 55-7
Walls AWG and Meurman JH (2012) Approaches to caries prevention and therapy in the elderly. Adv Dent Res 24(2): 36-40