Oral Health for Caregivers Part 3 - Hands-onPractice and ... Health... · plaque are not in the mouth all night. ~ Get ready to brush • To prevent pulling or cracking of the lips,

Oral Health for CaregiversPart 3 - Hands-on Practice and Demonstrations - Script

Daily Routines - Flossing & Brushing; Denture CareThe Uncooperative Cl ient;

Monitoring Oral Health; Referrals

The next pages contain step-by-step directions for performing oral health care.

If teaching a lO-hour class, set up stations for the oral health activities.Demonstrate; have students work in groups of 3 to read the steps, demonstratethe activity, and record the proficiency. Everyone gets a turn at each aspect.See "Proficiency Stations" at the end of this section, p. 3-12 to 3-14.

If teaching a 5-hour class, introduce the activities within the slide program andallow time to practice the skills.

Daily Routines[;J Personal Health Activity

• Mouth care is a very personal and sensitive activity that you canperform caringly and confidently.

• You might have a client who is uncooperative or who refuses toallow you to perform your duties. Other clients may not be able tokeep their mouths open very well. With practice and patience youwill learn to perform daily care.

I;] Protect Yourself and Your Client• Consider your safety when working with such clients.

o Use a mouth prop or other device (a rolled washcloth workswell) to keep the client's mouth open if biting is a concern.

o Do not insert your fingers between your client's upper and lowerteeth if there is a chance that you could be bitten.

o Work from behind the client if there is a chance of being hitduring oral care.

Trainer - Hands-on Practice - Script 3 - 1

• Practice good body mechanics to decrease the chances of injuringyourself.a Avoid unnecessary twisting and reaching while performing oral

care.a Choose to work from the position most comfortable for you and

for your client's situation, whether from the back or theside/front.

a Try different positions to find the ones that work best. Askyour client to turn his/her head (if mobility allows) to makeyour tasks easier.

• Infection Control IssuesTo protect against cross-contamination, follow Infection ControlGuidelines and Universal Precautions when performing oral care.a Wash hands before and after oral care.a Wear gloves and other protective gear. Depending on your

client's medical situation and your risk for infection, the extrasmay include a mask, gown or apron, and safety glasses orgoggles.

a Be careful not to touch the toothbrush bristles or any of theoral health items to other surfaces such as the counter, thesink, your bare hands, etc.

a Do not contaminate faucets, drawer handles, or other surfacesby touching with gloves that have been in contact with theclient's mouth.

a Use a clean paper towel when turning faucets on and off (whenwetting toothbrush or scrubbing dentures) to preventcontamination of your gloves.

a Gather all of your supplies before you start.

[;] Suggested Supplies - Flossing & Brushing (See "Tool Kit" Contents.)For clients with natural teeth (no removable appliances ordentures):Gloves, mask, goggles, gown or apron, as neededBasinPaper cup with small amount of waterTowel to place on client's chest


Paper towelsLubricant for lips (Vaseline) on applicator (Q-tip)Dental floss-about 18 inches ORFloss holder loaded with flossMoistened soft toothbrush with fluoride toothpasteOther aids (mini-brushes for cleaning between the teeth, toothpicks,or dental sticks) as needed or per client's preference

~ Get ready to floss and brushAsk your client if s/he can eat comfortably and if there are any soreareas in the mouth.To prevent pulling or cracking of the lips, place a small amount ofVaseline on a swab and apply to the lips.Watch for any sore areas, changes in tissue, or anything unusual.

~ Flossing RoutineFloss once each day to clean between teeth where the brushmissesFlossing before brushing allows you to loosen and remove food andplaque from between the teeth, then brush and rinse it away.

*Caution: If your client has not flossed before, the gums may bleedwhen you try to floss. If s/he has heavy calculus or tartar deposits onthe teeth, you may have difficulty getting the floss between theteeth. This is a situation beyond your scope of practice and youshould record and report.

Professional cleaning and instructions in oral hygiene techniques bythe dentist or hygienist probably will be needed.

Floss with fingers: .• Follow a pattern so no teeth are missed.• Use about 18 inches of floss; wrap loosely around 1 finger on each

hand.• Slip the floss gently between the first 2 teeth, pull the floss tight

against one tooth (make a "C" shape around the tooth), gently slidethe floss under the gum and scrape the plaque from the teeth inabout 5 up-and-down motions.


• Move to the adjacent tooth and do the same thing.• Be careful not to cut the gum or jam the floss into the gum.• Remove the floss and move to the next 2 teeth. As the floss

becomes soiled, unwind the floss from one finger and wind on theother.

• Allow the client to rinse or swish with water and to spit it out.

Floss with holder:• Follow a pattern so no teeth are missed.• Load floss on the holder or use single-use flossers.• Use the holder in the same manner as described above, being

careful not to cut or damage the gum tissue.• You may need to "saw" back and forth to get the floss to slide

between the teeth. Try to work the floss in an up and down motionas much as possible when cleaning the teeth.

• Allow the client to rinse or swish with water and to spit it out.

Trainer - Hands-on Practice - Script 3-4

~ Brushing RoutineBrush two times per day, after breakfast and before bed• The bedtime brushing is the most important one.

We must clean our mouths at the end of the day so that food andplaque are not in the mouth all night.

~ Get ready to brush• To prevent pulling or cracking of the lips, place a small amount of

Vaseline on a swab and apply to the lips. (It is not necessary toreapply if you have just completed flossing.)

• Wet the toothbrush. Place just enough fluoride toothpaste on thebrush to cover the bristles.

• Be sure that your client's head is stable. Have the client lean intoa chair back or cradle his head in your arm.

[;J Follow a routine for brushing• Clean entire mouth with brush or toothette** (including tongue and

all surfaces of teeth), using gentle motions.• Follow a pattern so no teeth are missed.• Place the bristles where the gums and teeth meet I make short

brush strokes (small circles, "jiggles or wiggles"), count to 5 in eacharea, move to the next small area. Repeat.

• Start on the outside of the upper right side, brush around to theupper left, then move to the upper left inside (near the roof of themouth) and around to the upper right inside. Brush the bitingsurfaces (grooves and pits hold food and germs) on all upper teeth.Repeat pattern for the lower teeth.

• Remember to brush the tongue and the roof of the mouth.• Continue in this manner until you have brushed the outside, inside,

and biting surfaces of all the upper and lower teeth.• Allow the client to rinse or swish with water and to spit it out.

o **Note: Toothettes, moistened gauze pads, or "Oral B BrushUps" may not adequately clean the teeth and may push foodfurther into the spaces between the teeth. They are useful incleaning mouth tissues when there are no teeth or just a fewteeth, or for a client who is comatose or unable to open hismouth.


o There have been incidents where the sponge came loose from aToothette and became lodged in the client's throat. Extremecare should be used with this device. It is best for tissue care,applying medications, moisturizing dry tissue, or for clearingsoft, non-attached soft debris from the mouth.

;] Rinsing• If the service/care plan allows or requires, have your client rinse

with fluoride rinse (over-the-counter item, such as ACT orFluorigard) or antibacterial rinse (prescription item, such aschlorhexidine).

• Follow directions exactly.• Avoid alcohol-loaded mouthwashes if your client has problems with

dry mouth.


Denture Carer;] Denture Care

Like natural teeth, dentures must be properly cared for to last.If the client does not have any teeth or wears dentures, the gums and

. mouth should be cleaned once or more each day.Watch for, document, and report any problems a client may have withdentures such as discomfort, trouble eating, speech problems,complaints of the dentures not fitting correctly, sore spots under oraround the denture, or odor.Use care in handling dentures. They can be very slippery and areeasily broken if dropped even just a few inches. Replacing brokendentures can be very expensive-several hundred dollars perdenture.Place a towel in the sink or fill the sink with water to preventdamage if the denture should drop.Do not soak dentures in bleach water. Bleach can remove the pinkcoloring, discolor the metal on a partial denture, or create a"metallic taste."

[;J Suggested SuppliesFor clients with dentures or partials:Gloves, mask, goggles, gown or apronBasinPaper cup with small amount of waterTowelPaper towelsDenture cupDenture cleaning tabletDenture brush with regular or denture toothpaste or mild liquiddetergentLubricant for lips (Vaseline) on applicator (Q-tip)Toothette or gauze padsMoistened soft toothbrush with fluoride toothpaste (if client hassome natural teeth)Dental floss (if client has some natural teeth)Floss holder loaded with floss (if client has some natural teeth)Other aids (mini-brushes for cleaning between the teeth, toothpicks,or dental sticks) as needed or per client's preference.


~ Get Ready to Clean Dentures or PartialsAsk your client if s/he can eat comfortably and if there are any soreareas in the mouth.To prevent pulling or cracking of the lips, place a small amount ofVaseline on a swab and apply to the lips.Watch for any sore areas, changes in tissue, or anything unusual.

• Brush daily.o Remove the'dentures or have the client remove the dentures,

lower first, then the upper.o To remove the upper denture: Have your client keep "loose lips"

while you gently slide your finger tips along the border of theupper denture from center front toward the back. When youreach the back edge, your fingers should be able to break thesuction that holds the denture in place.

o Rinse with cool running water before brushing.o Peel off any denture adhesive that may be present on the

denture.o Use a regular toothbrush or a denture brush with toothpaste or

denture toothpaste. Denture toothpaste is less abrasive thanregular toothpaste and therefore better for the dentures.

o Scrub thoroughly.o Rinse completely.o Return dentures to client.o Be sure your client's mouth is clean before you reinsert the

denture.

• Soak overnight.o Never soak dirty dentureslo Brush dentures as outlined above.o Rinse denture cup and fill with cool water and denture cleaning

product.o Place clean (brushed) denture in clean denture cup.o AIlow denture to soak overnight , (or for several hours,

depending on dentist's recommendations or clients' preference).o In the morning, drain the used water. Clean denture cup.o Scrub the denture to remove loosened debris. Rinse well.o Return denture to client.


o Note: Some people like to sleep with their dentures in theirmouths. In some cases, a dentist may even recommend this.This is okay IF dentures are cleaned thoroughly before bed.Additional daytime cleanings or even a one- or two-hour daytimesoak could help make up for the lack of overnight soaking.

• Gently brush the gums, roof of the mouth, and the tonguebefore reinserting the denture.o Use a soft toothbrush, a moist washcloth or gauze pad, a

toothette (small sponge on a handle), or Oral B"Brush Up" toclean these areas. A small amount of toothpaste can be used onthe brush or toothette to give a fresh taste.

o Note: Toothettes, washcloths, gauze pads, and Brush Ups maynot adequately clean the teeth and may push food further intothe spaces between teeth. They are useful in cleaning mouthtissues when there are no teeth or just a few teeth, or for aclient who is comatose or unable to open his mouth. There havebeen incidents where the sponge came loose from a Toothetteand became lodged in the client's throat. Extreme care shouldbe used with this device. It is best for tissue care, applyingmedications, moisturizing dry tissue, or for clearing soft, nonattached soft debris from the mouth.

o Warning: "Do not put any liquids, toothpaste, etc. in the mouthof a client who is comatose, combative, or has swallowingdefects. Use a toothbrush dipped in mouthwash to brush thegumline, teeth, and inside the mouth."

• Check for cracks, sharp edges, or broken teeth.o If you find cracks, sharp edges, or broken teeth, notify your

supervisor or your client's case manager.o DO NOT attempt home repairs.o If you do NOT find a problem, return denture to client.o Rinse and clean the denture cup and supplies.o Remove gloves and wash hands.o Return supplies and denture cup to proper storage.o Record procedure. Report observations if necessary.


The Uncooperative Client~ Dental Care and Uncooperative Clients

• Protect yourselfWork from behind and NEVER place your fingers between theteeth if there is a fhance that you could be bitten.

• Create a favorable environmenta Try to find a time or location that is comfortable for your

client and comfortable for you.a Begin with "show-tell-do."

Show your client the toothbrush or floss.Tell him/her what you would like to do.Do it.This shows respect and prepares the client for care.

a Try soothing your client by:Asking (another) family member to hold client's handGently cradling client's head while workingSinging or telling a story

• Other Tipsa If client is reluctant to open mouth, try tapping gently with

toothbrush along cheek toward mouth. Often this willencourage folks to open.

a If client is unwilling or unable to open teeth but you can get afinger inside the lips, you may be able to brush the outside ofthe teeth and clean out any food the client may be pocketingthere.

a Just do the best job you can. Try again tomorrow.


Monitoring Oral Health~ Oral Inspection

• Ask daily:a Are you able to eat comfortably?a Are you having any pain or discomfort?

• Monitor teeth, gums, tongue, lips monthlya Use a flashlight to look for red or white areas, sores, or other

abnormalities. You can wrap the flashlight in plastic wrap or asandwich bag to prevent cross-contamination.

a Pick a date to inspect each month. Mark on the calendar!a This is in addition to the observations you make every day

during oral care.a Follow the same pattern that you use in brushing and flossing.a (Example: Start on the upper right outside, work around all of

the outside areas, then move to the inside of the upper, workingback to the upper right. Follow the same routine for the lowerteeth. Pull the lips out and check the space between the lipsand the gums. Also check the tongue.)

a Be sure to record and report any problems.a Any areas that don't heal within 2 weeks should be checked by a

physician or a dentist.

• Replace toothbrush every 3 months (or sooner if the bristlesare frayed) or after an illness like the flu or a cold.a Dentists recommend soft brushes because they are more gentle

on teeth and gums.

~ When and How to Refer• If you see something unusual, record in the service/care plan and

report to your supervisor or your client's case manager.• Identify what you see, where it is, the size, color, and shape, and

any other important observations.• Your supervisor or your client's case manager will then determine

the appropriate action.• Sores in the mouth that do not heal within 2 weeks should be

checked by a medical or dental provider.


Oral Health for CaregiversProficiency Stations for Hands-on Practice

Divide into groups of 3: A performer, a reader/observer, a recorder. Eachtrainee will participate in all 3 activities at each station. You will find the"Hands-on Practice Checklist" in trainer's manual. Provide one for each student.

Performer will demonstrate the skills.

Reader/observer will coach performer on the steps to follow for eachprocedure, using the "Hands-on Practice" text from your manual.Recorder will mark the skills completed on Checklist. Recorder may also serveas the "client" for some stations.

Station 1: Flossing, Brushing, Other AidsSupplies: Dental floss, floss holders, toothbrushes, fluoride toothpaste,interproximal brushes, adaptive aids (commercial or home-made), mouth model.

Station 2: Denture CareSupplies: Denture or partial denture, or mouth model, or photos of dentures &partials; denture brush, denture toothpaste, denture cleaner product or mild(dishwashing) detergent.

Station 3: Uncooperative ClientSupplies: Toothbrush, toothpaste, washcloth or other mouth props.(The "client" may perform as an uncooperative person.)

Station 4: Monitor & Document"Oral Health Photo Guide," flashlight, baggie or Saran Wrap, pen or pencil.Pretend to inspect your "client's" mouth, describing the pattern that you follow:Teeth, gums, cheeks, lips, tongue. Start on the upper right "outside," move tothe upper left "outside," then to the upper left "inside," to the upper right"inside." Do the same for the lower. Check the lips and tongue.


Station 4: Monitor & Document

Using the "Oral Health Photo Guide," choose one photo and pretend that younotice something unusual in your client's mouth when performing your monthlymonitoring.

Write below what you would record in the service/care plan.Answer all that apply.

What do you see?

Where do you see it?

What is the size?Measurement, like";} inch" or "t inch"Description, like "the size of a pencil eraser" or "the size of a dime"

What is the color? Brown, black, red, white, combination?

What is the shape? Round, irregular, long, thin, thick?

Is it tender or painful?

Is it blistered or is it crusty?

Is it "weeping" or "oozing"?

Any other observations?

Today's date _.....0.- _

Date to re-check (2 weeks from now) _


Oral Health for CaregiversHands-on Practice Checklist

Student Name _ Date _

Station & Skills Completed ObserverSWIPES technique used; supplies gathered (Check) InitialsStation 1: Flossing, Brushing, Other AidsA. Flossing

Uses fingers to floss between all teeth and behind the lasttooth.Uses floss holder to demonstrate the same.

B. BrushingDispenses fluoride toothpaste to brush (imaginary).Brushes all upper and lower teeth using gentle circular or smallvibrating motions, following a pattern so no teeth are missed.Brushes the tongue (imaginary).

C. Other AidsDemonstrates the use of interproximal (mini) brushes.Demonstrates how to fashion and use adaptive aids for flossingor brushing.Describes use of fluoride rinse.

Station 2: Denture CareA. Applies denture toothpaste or mild soap (imaginary) to denture

brush.Brushes all teeth and the under side of denture.Rinses denture. Inspects for cracks, chips, or sharp edges.Returns denture to client.

B. Soaks denture with commercial product (imaginary).

Brushes soaked denture. Inspects for cracks, chips, or sharp

edges.Returns denture to client.

Station 3: Uncooperative ClientA. Demonstrates use of washcloth or mouth prop.

Uses "Show-Tell-Do" technique with "client."Demonstrates how to cradle "client's" head for stability.

Station 4: Monitor & DocumentA. Inspects client's mouth using a flashlight.

Follows a pattern so no areas are missed: Teeth, gums, cheeks,

lips, tongue.

B. Documents unusual findings: Location, si ze, color, shape, othersignificant observations. (See previous paqe for quidance.)
