Explanation
Children experience tooth eruption as their physical development proceeds. In particular, disabled children with dysphagia may show many differences intraorally compared with typically developing children and often require intervention. It is therefore important to provide appropriate oral care with an understanding of the characteristics of the oral cavity in children.
Explanation
① Understanding the need for pediatric oral care
Pediatric oral care is not concerned solely with the oral cavity. It also plays a role in general physical health such as by preventing pneumonia. The oral cavity undergoes structural and environmental changes in childhood such as tooth eruption and the emergence of healthy permanent dentition. So, selecting suitable oral care tools to use at a particular period of development and oral morphology enhances the effectiveness of oral hygiene measures given at optimal times. For severely disabled children with dysphagia, oral care must go hand in hand with close monitoring during oral care provision, due to factors such as systemic stress or breathing difficulties from the irritation caused by brushing the teeth, and mouth opening and posture.
Explanation
① when deciduous dentition erupts and ② when it is replaced with permanent dentition
Deciduous dentition (20 teeth in total) is generally described with letters and permanent dentition (28 teeth, excluding the wisdom teeth) is described with numerals. The first permanent tooth to erupt is molar 6 (the first molar), and at around the same time, the deciduous teeth start to become loose and are replaced with permanent teeth. During this period when the dentition changes, children are prone to disruptions in swallowing function and pronunciation, so we need to consider providing guidance on eating and type of foods eaten. Children with disablement such as Down's syndrome show delayed tooth eruption compared with typically developing children.
Explanation
① the need for oral care and ② management of time-related risks
Oral care should be carried out after each meal to maintain oral hygiene. However, in reality, this frequency is often not possible. So, thorough oral care needs to be carried out before children go to bed because salivary secretion is reduced during sleeping and microbes in the oral cavity may proliferate. For children who are tube fed, oral care provided before feeding stimulates salivary secretion, which is linked to alertness. Frequent vomiting leads to decalcification of the tooth enamel through gastric acid and to the child refusing to eat, so we must consider timing and posture when providing food.
Explanation
Understanding the types and purposes of oral care tools used with children
Oral care is aimed at training the senses and inducing sensations as well cleaning the oral cavity. Children are accustomed to touching inside and around the oral cavity, putting their hands and fingers in their mouths during the first half of infancy. With the initial eruption of the deciduous front teeth in the mandibular arcade, children can gradually become accustomed to their teeth being brushed by putting a silicon-type brush inside their mouth or using gauze or wet wipes for wiping. It is essential, however, to watch when children put a toothbrush into their mouth themselves. A good toothbrush for children is basically one with a small head and a straight handle that is can be easily inserted into narrow spaces. Toothbrushes should be changed promptly when the bristles spread outward because this greatly reduces the effectiveness of cleaning with them. Electric and ultrasonic toothbrushes are highly effective for cleaning when they are applied to the surfaces of the teeth, but children might refuse to use them because of the vibrations or noise. Electric and ultrasonic toothbrushes can be used as sensory stimulation for children with reduced sensitivity.
Explanation
When the number of teeth increase, the gaps between the teeth and smaller newly erupted teeth can't be thoroughly cleaned with a toothbrush, so additional cleaning tools need to be used. Holder-type dental floss is easy to use and can avoid cutting the fingers. Tongue brushes and sponge brushes are appropriate to use when patient have coating on the tongue or secretions have accumulated. However, be careful that the sponge does not become stuck if the patient bites it too hard. Using either of these tools without any preparation carries a risk of injuring the membranes with hard bristles or a hard sponge. So, dip the tool in water once before starting to use it in a well-moistened oral cavity.
Fluoride toothpastes are effective against tooth decay when used daily. In particular, fluoride can easily be absorbed by recently erupted permanent teeth. For children who can't gargle, we can use a fluoride toothpaste that does not require mouthwash or a spray-type toothpaste.
Explanation
Control of positioning when providing pediatric oral care
The general recommendation when brushing the teeth of young infants is to have them lay down on a bed and then brush their teeth with their mouths clearly visible. This might not be a suitable method to use with disabled children though. When children dislike their teeth being cleaned after being put on the bed, they can sit or stand and be helped to clean their teeth; at this time, caregivers positioned behind them should support the child's lower jaw with the nondominant hand.
Explanation
① hold the lips and cheeks and ② the importance of examining the oral cavity
Before providing oral care, hold the lips and cheeks and check the oral cavity for plaque, ulcer, trauma, and any loose teeth and the extent of looseness. If there is ulceration or damage to the mucosa, the question of whether to provide oral care arises and this is also linked to early treatment. If the perioral muscles are tight, stretching exercises are often effective. Hypersensitivity can be linked with children's acceptance or refusal of oral care; so, it's important to touch the area around the mouth before starting oral care to get them accustomed to the feeling of touch there.
Explanation
Understanding standard techniques for pediatric tooth brushing
In young children, the superior labial frenulum is visible on the inside of the upper lip. If the bristles of a toothbrush come into contact with this frenulum, it can be painful, and this pain can make children refuse tooth brushing. In such cases, caregivers should place their fingers on the superior labial frenulum, to act as a guide to prevent the bristles contacting this area. The teeth should be cleaned in a certain order, starting at the back (molars) and with small brushing motions to the extent that the bristles lean to the front. When cleaning the teeth surfaces, on the front side and then the back side, hold up the lips and cheek mucosa with the fingers of the other hand that is not being used for brushing. When brushing the back side of the teeth, keep holding the lower jaw firmly downward to keep the mouth open. However, be sure to watch the child carefully while doing this because breathing can stop, or breathing difficulties can develop, with the mouth open. When water was used before brushing, incline the child's head forward to ensure the water leaves the mouth, to prevent aspiration.
Explanation
① reasons for refusal of oral care and ② oral care techniques in cases of hypersensitivity
Hypersensitivity, psychological factors, and stimulation of the bite reflex are major reasons for children to refuse oral care.
In cases of hypersensitivity, we should try to desensitize areas that are normally sensitive. When children with strong sensitivity can't bear the irritation from using a toothbrush, use a sponge brush or a soft-bristle brush with low irritability so that the child gradually becomes accustomed to brushing.
When children reject tooth brushing for psychological reasons, we can try, for example, a different caregiver doing the brushing, finishing brushing on the count of 10, brushing while the child listens to or watches music or a video they like, and using a toothpaste with the child's favorite flavor. Not all children respond the same, so we need to observe them to find something that draws their interest. To increase children's comfort with tooth brushing, we can divide up tooth brushing into a number of short sessions rather than trying to complete it all in one go, and praise them at the end of each short session.
When children with a bite reflex bite down on the toothbrush, remove it when the bite force weakens-don't try to remove it forcefully. We can use an oral speculum when it is difficult to keep the child's mouth open by hand, but take care that teeth don't loosen or fracture with strong biting on the speculum.
Explanation
① the need for palatal care and ② special techniques for palatal care
The palate changes as children grow, but it's difficult to remove food debris from the palatal creases in children with a narrow palate. This can be done with a sponge brush or, when it is very narrow as shown in Figure 10, by scraping gently with a soft long-bristle brush. Be careful not to brush the palate too hard. If there is hard build-up there, soften with a moisturizer and then remove it gradually.
Explanation
① during the transition from deciduous dentition to permanent dentition and ② for children at high risk during this period
As the front teeth are replaced, the permanent and deciduous teeth may overlap for a time, and plaque can accumulate between the front and rear teeth in this alignment. However, brushing loose teeth is difficult. If a tooth is only slightly loose, we can place a finger lightly on the top of the tooth to fix its position, which help with tooth brushing. When the tooth looks like it might be lost, consider having a dentist remove it at the appropriate time to reduce the risk of accidental ingestion.
Explanation
① the causes of gingival enlargement and ② care techniques for children with gingival enlargement
Gingival enlargement can occur as an adverse drug reaction to anticonvulsants. When probed with a finger, drug-induced gingival enlargement is hard and not sufficiently clean. Gingival enlargement can also be accompanied by complicating gingivitis. Gingivitis can be readily determined if the gums are tender to touch and bleed easily. When it's difficult to apply the bristles of a toothbrush, use a tuft brush or a small brush for thorough dental polishing. Depending on the size and location of the gingival enlargements, the respiratory airway can be obstructed, and management beyond regular oral care may be required and/or there may be problems with occlusion. Consult a dentist in such cases.
References
- Japanese Society of Pediatric Dentistry: On the Timing of The Emergence of Baby And Permanent Teeth in Japanese Children Research, Pediatric Dentistry,26(1):1-18,1988.
- Mami Endo: Dental and Oral Care and Health Care for People with Disabilities.Dentistry for people with disabilities.Nagasue Shoten.Tokyo. pp.116-123, 2014.
- Miki Kosaka: Oral Care.Severely handicapped children in the picture(care of. Intermedica. pp.142-157, 2015.
