Oral Hygiene Instruction with Limited Dexterity

Case 3Oral Hygiene Instruction with Limited Dexterity

CASE STORY

A 59‐year‐old female presents at the dental office for complete dental evaluation and states, “I feel like some of my teeth are loose.” One year ago the patient suffered a spinal cord injury, seriously damaging her C5 and C6 vertebrae. She uses a walker for balance, has moderate functioning level, with limited mobility on the right side of the body. A home health aid is present with the patient and helps her with household duties three to four days a week. The patient states that prior to her accident she was physically fit and active. She was an avid runner, swimmer, and tennis player and states she had no health or dental problems, and only visited health‐care providers when she experienced pain.

PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Identify potential barriers to patient care when creating plan for oral hygiene instruction after nonsurgical periodontal therapy
• Create a dental hygiene instruction plan to include the patient and caregivers as cotherapists
• Identify when changes in oral hygiene educational instruction are necessary
• Provide positive feedback and instruction for the patient

Dental History

The patient reports no dental treatment for at least five years. Unless she experienced pain or discomfort, the patient did not routinely seek dental care. She brushes one to two times per day with a powered toothbrush and occasionally uses waxed floss for interproximal cleaning. Since noticing tooth mobility, the patient avoids chewing on her right side.

Medical History

One year ago the patient suffered a spinal cord injury after a car accident. The accident left the patient paralyzed from the chest down due to injury to the C5 and C6 vertebrae. After intense physical and occupational therapy, the patient has regained some of her mobility with the use of a walker. She currently takes no medication, but following her accident she was prescribed and took corticosteroids for inflammation of the spinal cord caused by the accident. She continues to receive physical and occupational therapy. She reports no known allergies.

• Vital Signs:
  • Blood pressure: 124/ 76 mmHg
  • Pulse: 68 beats/min
  • Respiration: 14 beats/min

Social History

The patient is a nonsmoker and reports no prior tobacco use. She consumes alcohol occasionally, having one to two drinks a week. Prior to her accident she was physically active. She ran three to four times a week, swam, and played tennis. Currently, she swims for exercise during her physical therapy sessions and continues to work with occupational therapists focusing on improvement with her manual dexterity. The patient runs a small business from her home and has not returned to previous full‐time employment due to her limited mobility. The patient who claims to be a lover of sweets, often snacks on a variety of candy and chocolate treats throughout the day.

Dental Examination

The intra‐ and extraoral examinations of the patient is within normal limits. The generalized appearance of the gingiva is deep red with blunted gingival margins in the upper right (UR) and lower left (LL) quadrants. Generalized recession ranging from 2 to 4 mm is noted on the mandibular arch. The patient complains of moderate root sensitivity to temperature and to the touch. Localized severe inflammation appears on teeth #1, #2, #3, #18, and #19. Generalized bleeding on probing occurs throughout the dentition with localized supragingival calculus located on the lower anterior teeth. Generalized moderate interproximal calculus is present. Slight crowding of the mandibular anterior teeth is noted. Exudate is present upon probing teeth #1, #2, #3, and #19. Class III mobility on #1, #2, #3, #18, and #19. Recurrent decay is present on tooth #20 and under the distal margin of the crown on tooth #4.

Radiographic Examination

Radiographic examination reveals severe bone loss surrounding teeth #1, #2, #3, #18, and #19. (See Figure 4.3.1).

Figure 4.3.1: Panoramic radiograph.

Dental Hygiene Diagnosis

Problems	Related Etiology
Periodontal disease and tooth mobility	Dental and oral health neglect; possible side effects of long‐term steroid prescription use
Recurrent dental caries	Past dental neglect; sugar rich diet; possible side effects of long‐term steroid use and patient disability
Root exposure and sensitivity	A loss of attachment, and biofilm accumulation

Planned Interventions

Clinical	Education	Oral Hygiene Instruction
Periodontal debridement and localized scaling and root planingTopical and local anesthetic for patient sensitivityAntimicrobial therapy5% fluoride varnish for root sensitivity and caries preventionFour to eight‐week re‐evaluation of gingiva and reinforcement of homecare routineThree‐month periodontal maintenance recall	Progression of periodontal diseaseEducate on importance of periodontal maintenance visits as required or 2 to 3 monthsEducate on adjunct therapies. and incorporate into daily oral home careNutritional counselingEducate on relationship between past medication use, diet, and dental caries	Modified Stillman’s technique with modification of toothbrush handle for patient grasp to accommodate patient’s disabilityFloss holder with modification of handle for interproximal cleaning including additional periodontal aides to accommodate patient’s abilityUse of fluoridated toothpaste and fluoride rinse

Progress Notes

The patient in case study three presented with severe periodontal involvement in the UR and LL posterior quadrants. Due to severe tooth mobility, presence of exudate, and the extent of bone and gingival attachment loss, extractions were the dentist’s recommendation for teeth #1, #2, #3, #18 and #19 (see Figure 4.3.2). The patient consented to extractions of teeth #1, #2, #3, #18 and #19 and full mouth periodontal debridement with localized scaling and root planing of teeth #12–#14, #20 and #30–#32 (See Figures 4.3.3 and 4.3.4).

Figure 4.3.2: Lower left radiograph of teeth #18 and #19 revealing furcation involvement.

Figure 4.3.3: Bitewing radiograph of left side showing advanced horizontal bone loss.

Figure 4.3.4: Bitewing radiograph of right side showing interproximal calculus with horizontal bone loss.

Discussion

Creating an oral hygiene care plan for a special needs patient after completing nonsurgical periodontal therapy involves complete assessment of the patient’s abilities and motivation. The healthy maintenance of the periodontium and supporting tissues continues to be imperative. Attitude and physical barriers may hinder compliance and personal oral hygiene care (Wilkins 2009, pp. 382–383). Upon initial examination the severity of the periodontal disease and expected outcomes must be considered as it relates to patient compliance, successful completion of treatment, and creation of an acceptable oral hygiene homecare regimen (Wilkins 2009, pp. 374–375). For optimal success, positive reinforcement and motivation are necessary and must be consistently provided throughout maintenance (Wilkins 2009, p. 383). This increases the opportunity for successful periodontal disease management and oral hygiene care.

The Modified Stillman’s toothbrushing technique is recommended over the Bass Method due to the patient’s gingival recession and root sensitivity. The Stillman’s method is considered less traumatic because the bristles are not directed towards the sulcus (Darby and Walsh 2003, p. 355). The modification adds a roll stroke, where the bristles are rolled occlusally to clean the entire facial and lingual surfaces after the cervical areas are cleaned (Darby and Walsh 2003, p. 355). For this patient, customizing oral self‐care devices is necessary. There are a variety of objects such as bicycle handle grips, soda cans, and tennis or soft rubber balls that may be used to enlarge the diameter of a handle and create an adaptive oral hygiene device to fit the patient’s grasp and closure abilities (Darby and Walsh 2003, p. 774). A wide variety of interdental aids are available for debris removal. When the interdental gingiva fills the embrasure space, biofilm removal is best accomplished with dental floss or dental tape. Manipulating the regular dental floss to form the c‐shaped flossing for wrapping around interproximal surfaces is impossible for this patient. For interproximal cleaning flossholders with enlarged diameter handles allow this patient to remove debris from areas that are not periodontally involved. If interdental gingiva is reduced or missing, the embrasure space is larger, as seen in between #18 and #19 (see Figure 4.3.2), and other methods of debris removal are needed (Darby and Walsh 2003, p. 361). Interdental brushes provide access to larger interdental spaces and come in a variety of shapes and sizes (Blue 2017, p. 497). The conical or tapered design is inserted into a handle and may be angled to fit interproximal spaces (Darby and Walsh 2003, p. 371). A single session of oral hygiene instruction is not sufficient for long‐term periodontal management or behavior change (Yuen 2013, p. 2). Frequent visits to monitor patient progress including written oral hygiene instruction on homecare are necessary aspects of patient care for a successful end result.

Take‐Home Hints

1. Barriers to consider for patient care include mental and physical barriers.
2. Patient compliance in daily oral hygiene self‐care is key to the success of oral hygiene health following nonsurgical periodontal therapy.
3. For effective debris removal for a patient with special needs, modifications may need to be made to toothbrushes and oral hygiene aides for grasping and use.