Oral Hygiene Instruction

Dr. Hardy Limeback
Authored by:
Dr. Hardy Limeback

Introduction

There are surprisingly few studies to show that oral hygiene instruction (OHI) effectively reduces dental decay experience. This paper briefly reviews the literature. The main goal of this article is to provide a recommendation for how to carry out an effective OHI session with a patient.

Evidence that OHI works to reduce dental decay risk

The effectiveness of educational interventions in changing people’s behaviour and achieving improved oral health was reviewed by Brown.1

The school setting

It has been shown that supervised oral hygiene in children effectively reduces gingivitis (inflammation of the gums) and dental plaque but children find it hard to establish good oral hygiene habits.2 Introduction to supervised tooth brushing very early on in primary school is effective in reducing plaque3 and dental decay rates.4 School based programs providing oral hygiene instruction result in better dental knowledge in improved oral health in young children5,6,7 and their skills at brushing teeth improve when they are motivated through games.8

The dental office setting

Frequent professional removal of dental plaque (e.g. every 2-4 weeks) is effective in reducing gingivitis and caries and additional oral hygiene instruction reduces plaque and gingivitis further.10 Comprehensive education programs in the dental settings can reduce dental decay experience.11,12,13 There is a link between caries risk and gingivitis scores.14 Good oral hygiene can reverse root caries (dental decay of the exposed roots of teeth).15

Does it matter how OHI is delivered?

It seems that using a video to instruct patients on how to conduct effective oral hygiene is equally as effective as personal instruction.16,17 However, some researchers found that children were more receptive to videotapes.17 Apparently teens learn to improve their oral hygiene better with recorded slide presentations than through verbal communication.18 Self instruction manuals are also an effective means of improving oral hygiene and reducing the risk for gingivitis.19 One group found that an intra-oral camera was more effective during oral hygiene instruction.20 Axelsson et al21 developed an effective way in delivering oral hygiene instruction that links to the patients self-assessed needs.

Who benefits the most from OHI?

Some dental practitioners have difficulty in determining who would best benefit from oral hygiene instruction22 and others have determined that patients in the low socioeconomic bracket receive more frequent oral hygiene instruction.23 Disabled persons appear to improve in oral health when OHI is included in the comprehensive preventive care program.24 Actually, anyone at high risk for dental decay would benefit from individualized oral hygiene instruction, according to Christensen.25 Home visits and oral care instruction to parents are particularly effective in improving oral health.26

How to effectively carry out oral hygiene instruction

The first list summarizes the recommended steps involved in conducting effective oral hygiene instruction. The health care provider will assess the patients ability to comprehend instruction and make a decision as to what level the communication will be effective (click here to take part in an online quiz that will help the operator select appropriate techniques for the operator-patient interaction).

An example of a patient undergoing OHI using a disclosing dye is shown in Figure 1. Staining teeth for plaque deposits can also be conducted using various other products on the market (e.g. Red-Cote disclosing solution or tablets http://www.gumbrand.com/, Two-tone Plaksearch disclosing solution http://www.oraldent.co.uk/plaqsearch.html).

Age-appropriate manual tooth brushing techniques are shown in table 2. The operator must decide the needs of the patient and the manual dexterity and select an appropriate brushing technique.

Conclusion

Although oral hygiene instruction may actually be one of the least effective preventive measures to reduce dental decay when there is poor compliance and a reluctance to change behaviour, motivated patients can achieve significant reduction in the incidence of caries and gingivitis when oral hygiene is consistently improved.

Recommended steps to conduct an effective OHI Session

Step 1. Patient orientation and introduction to their mouths

  • Show the patient his/her own oral tissues (‘gums’, teeth, exposed root surfaces, tongue etc.) using a hand mirror
  • Discuss the relationship between plaque and caries using the teaching aids (diagrams of teeth covered in plaque, cut-away diagrams with caries penetrating enamel, dentin and pulp)
  • Show the patient’s own dental tissues on the BW radiographs
  • If plaque is very prominent intraorally, use a periodontal probe to pick up a sample to show the patient

Step 2. Disclose plaque and let the patient demonstrate his or her usual hygiene practices

  • Use Butler “Red Cote” (D & C Red #28 dye) tablets or drops (coat lips with petroleum jelly to avoid staining the lip pink) or use sodium fluorescein (Plak-Lite system) with blue-filtered light
  • Drop 4 to 5 drops on the tongue, ask the patient to “swish and lick all the teeth, front and back then spit out” (if the patient is very young, paint on the dye with a cotton swab, rinse, suction…make it fun!)
  • Rinse thoroughly with water, use the saliva ejector, air blast to remove all excess stain
  • Demonstrate the plaque to the patient with a hand mirror indicating the areas that were missed, then ask the patient to show you how oral hygiene is normally carried out at home (some patients have trouble getting all the plaque despite knowing exactly where they missed with the toothbrush)
  • Observe problems in dexterity, orientation of brush head etc.

Step 3: Show patients with a hand mirror the plaque that was missed, then ask them to demonstrate how they brush their teeth.
example: see Figure 1.

Step 4: Demonstrate appropriate brushing technique

  • For a child with limited dexterity, demonstrate in the child’s mouth with parent present the simple ‘roll’ technique.
  • In adolescents and adults demonstrate in the patient’s mouth with the patient looking in the hand mirror the Bass or Modified Stillman techniques
  • Ask the patient to try the technique (while you hold the hand mirror) and then allow him/her to inspect the teeth to see if all the plaque was removed
  • Repeat if required

Step 5: Introduce flossing

  • If dexterity is evident, introduce a flossing technique suitable for the patient
  • Studies have NOT been carried out to conclusively answer these questions:
  1. Does waxed floss leave wax and increase plaque growth?
  2. Do the high tech flosses (e.g. made with Gortex) remove less plaque than the threaded flosses?
  3. Are tape flosses and ‘super’ flosses superior to ordinary floss?
  4. Is floss containing fluoride or xylitol superior to ordinary floss in reducing the risk for caries?

Step 6: Introduce specialized tools to assist in plaque removal

  • introduce floss loops, super floss for bridge work and orthodontics
  • consider sonic brushes for the disabled, patients with manual dexterity problems, or non-compliant patients

Scrub or Fones Method - Circular/Horizontal Action  

The teeth are held in occlusion and the brush is pressed firmly against the teeth and gums and revolved in circles with as large a diameter as possible. This motion is combined with an intermittent horizontal scrubbing action on occlusal and lingual surfaces.

Summary of different brushing techniques

Rolling Stroke Method - Vertical Action

The brush is placed on the teeth and gingiva (in the area of the gingival margin) with the bristles directed apically. Pressure is then applied to the brush and the bristles are swept or rotated from the gingiva toward the occlusal surface of the teeth. This procedure is performed in a logical sequence cleaning all buccal and lingual surfaces in each dental arch. This method is commonly taught to schoolchildren as the method, which "brushes the teeth the way they grow."

Vibratory Action

These methods are designed to improve the cleansing of sulcular and interproximal areas. The sides or ends of the bristles also provide gingival massage and therefore these techniques are particularly helpful in cases where periodontal disease is present. These methods provide excellent cleansing but are technically more difficult than the two methods described above. All of these procedures follow a logical sequence in cleaning buccal and lingual surfaces in each dental arch, and must be followed by thorough rinsing to remove dislodged plaque.

Bass Method (also known as the Sulcular Technique)

A soft brush is placed with its bristles inserted into the gingival sulcus at an angle of roughly 45° to the tooth and vibrated gently back and forth.

Modified Stillman Method

The brush is placed on the teeth and gingiva in the area of the gingival margin, with the bristles directed apically. Lateral pressure is then applied to cause gingival blanching. The bristles are then vibrated gently back and forth and at the same time swept occlusally, with a rolling action (similar to that used in the Rolling Stroke method).

 

References: 

Brown LF. Research in dental health education and health promotion: a review of the literature. Health Educ Behavior 1994;21:83-102.

Lindhe J, Koch G. The effect of supervised oral hygiene on the gingivae of children. Lack of prolonged effect of supervision. J Period Res 1967;2:215-220.

Leal SC, Bezerra AC, de Toledo OA. Effectiveness of teaching methods for toothbrushing in preschool children. Braz Dent J 2002;13:133-136.

Rong WS, Bian JY, Wang WJ, Wang JD. Effectiveness of an oral health education and caries prevention program in kindergartens in China. Commun Dent Oral Epidemiol 2003;31:412-416.

Redmond CA, Blinkhorn FA, Kay EJ, Davies RM, Worthington HF, Blinkhorn FA. A cluster randomized controlled trial testing the effectiveness of a school-based dental health education program for adolescents. J Pub Health Dent 1999;50:12-17.

Worthington HV, Hill KB, Moonay J, Hamilton FA, Blinkhorn AS. A cluster randomized controlled trial of a dental health education program for 10-year-old children. J Pub Health Dent 2001;61:22-27.

Curnow MM, Pine CM, Burnside G, Nicholson JA, Chesters RK, Huntington E. A randomised controlled trial of the efficacy of supervised toothbrushing in high-caries-risk children. Caries Res 2002;36:294-300.

Swain JJ, Allard GB, Holborn SW. The good toothbrushing game: a school-based dental hygiene program for increasing the toothbrushing effectiveness of children. J Appl Behav Anal 1982;15:171-6.

Lindhe J, Axelsson P. The effect of controlled oral hygiene and topical fluoride application on caries and gingivitis in Swedish schoolchildren. Commun Dent Oral Epidemiol 1973;1:9-16.

Axelsson P, Lindhe J. Effect of oral hygiene instruction and professional toothcleaning on caries and gingivitis in school children. Commun Dent Oral Epidemiol 1981;9:251-255.

Holt RD, Winter GB, Fox B, Askew R: Second assessment of London children involved in a scheme of dental health education in infancy. Community Dent Oral Epidemiol, 1989;17:180-182.

Truin GJ, Plasschaert AJM, Konig KG, Vogels ALM: Dental caries in 5-, 7-,9- and 11-year-old school children during a 9-year dental health campaign in The Hague. Commun Dent Oral Epidemiol 1981;9:55-60.

Blinkhorn AS, Downer MC, Mackie IC, Bleasdale RS: Evaluation of a practice based preventive programme for adolescents. Commun Dent Oral Epidemiol 1981;9:275-279.

Okada M, Kuwahara S, Kaihara Y, Ishidori H, Kawamura M, Miura K, Nagasaka N. Relationship between gingival health and dental caries in children aged 7-12 years. J Oral Science 2000;42(3):151-5.

Nyvad B, Fejerskov O. Active root surface caries converted into inactive caries as a response to oral hygiene. Eur J Oral Sci 1986;94:281-284.

Lim LP, Davies WI, Yuen KW, Ma MH. Comparison of modes of oral hygiene instruction in improving gingival health. J Clin Periodontol 1996;23:693-697.

Lees A, Rock WP. A Comparison Between Written, Verbal, and Videotape Oral Hygiene Instruction for Patients with Fixed Appliances. J Orthodont 2000;27:323-328.

Lachapelle D, Desauliers G, Bujold N. Dental health education for adolescents: assessing attitude and knowledge following two educational approaches. Can J Public Health 1989;80:339-344

Glavind L, Zeuner E, Attstram R. Oral cleanliness and gingival health following oral hygiene instruction by selfed-educational programs J Clin Periodontol 1984;11:262-273.

Willershausen B. Schlosser E. Ernst CP. The intra-oral camera, dental health communication and oral hygiene. Internat Dental J 1999;49:95-100.

Axelsson P, Buishi YA, Bardosa MF, Karsson R, Prado MC. The effect of a new oral hygiene training program on approximal caries in 12-15-year-old Brazilian children: results after three years. Adv Dental Res 1994;8:278-284.

Milgrom P, Weinstein P, Melnick S, Beach B, Spadafora A. Oral Hygiene Instruction and Health Risk Assessment in Dental Practice. J Pub Health Dent 1989;49:1752-1725.

Tickle M, Milsom KM, King D, Blinkhorn AS. The influences on preventive care provided to children who frequently attend the UK General Dental Service. Br Dental J 2003;194(6):329-32; discussion 318.

Stiefel DJ, Rolla RR, Truelove EL: Effectiveness of various preventive methodologies for use with disabled persons. Clin Prev Dent 1984;6:17-22.

Christensen GJ. Special oral hygiene and preventive care for special needs. J Amer Dent Assoc. 2005;136(8):1141-3.

Kowash MB, Pinfield A, Smith J, Curzon ME. Effectiveness on oral health of a long-term health education programme for mothers with young children. Br Dent J 2000;188:201-205.