Oral care - Module 151
We reveal our top tips for keeping teeth and gums healthy and patients out of the dentist's chair
how to brush teeth effectively
• advice to give on teething trouble
• the advantages of electric toothbrushes
• why mouthwash should be used.
Download a pdf version of this module here
Download the Test Your Knowledge questions here
Most people take steps to manage their oralcare every day, from brushing their teeth to using floss or mouthwash. But while the dentist is seen as the main port of call for tooth trouble, pharmacies stock a wide range of products that are just as important in the battle against decay.
The importance of good dental hygiene can't be understated: according to the World Health Organization, 60-90 per cent of children and the vast majority of adults develop a cavity at some point in their life. In addition, wisdom teeth extraction is one of the most common operations in the UK.
Tooth brushing
Dental cavities are caused by bacteria. Plaque, which is a yellowy substance, contains bacteria that feed on sugars in the mouth, producing acids that cause tooth decay. Therefore to stop cavities, patients should brush away the plaque.
Correct tooth brushing technique can also help prevent gum disease, which is the leading cause of tooth loss in the UK. Gum disease is indicated by bleeding gums; plaque accumulates around where the gums meet the teeth, causing inflammation. If the condition is not treated, periodontal disease can occur, which can result in the loss of the tooth.
The best way to look after teeth is to brush them twice a day (in the morning and at night), removing plaque. Brush with small, circular movements using a pea-sized blob of toothpaste that contains fluoride, tilting the bristle tips to a 45 degree angle against the gumline.
Toothbrushes should be replaced when they are worn, which should be around every three months.
Cleaning a child's teeth can be difficult for parents. Great Ormond Street Children's Hospital recommends the following:
• Stand or sit behind the child, cradling their chin in your hand so you can reach the teeth easily
• Use a smear of toothpaste for children less than three years, or a pea-sized amount for older children
• Encourage the child to spit out excess toothpaste. Do not rise with water, as this removes the effect of fluoride. Do not allow the child to eat the toothpaste
• Use small, circular movements and try to concentrate on one section at a time. Brush behind the teeth and on to gums.
Mouthwash and floss
Patients should also be advised to clean between their teeth using floss, or using a fluoride-containing mouthwash. Recommend alcohol-free mouthwashes as other types have been linked to mouth cancer. If the patient has gum disease, a chlorhexidine-containing mouthwash can be used, but only for short periods as bacteria will become resistant and the treatment will stop working. Customers should also be warned chlorhexidine mouthwashes can cause staining, and should not be used within 30 minutes of brushing with toothpaste, as they can be incompatible with some the ingredients.
Bad breath
Another major concern for patients is bad breath, or halitosis. This can be caused by bad oral hygiene (bacteria creating the smell), diet (particularly crash diets, which can make the breath smell sweet), or taking certain medicines.
It's hard to smell your own breath, but a good test is to lick your wrist, wait for 10 seconds, and then smell it.
Bad breath is prevented by good brushing and flossing, and cleaning the tongue with a toothbrush or scraper. Some mouthwashes can also help, although most act as a perfume to mask the smell rather than treat the cause.
Black hairy tongue
One of the most alarming oral problems is black hairy tongue – which looks exactly like it sounds. This is actually harmless, and is caused by an overgrowth of bacteria or fungus on the tongue. It is more likely to develop in people with poor oral hygiene, who smoke, who are dehydrated, or have been using antibiotics (which can kill the natural bacteria on the tongue).
The condition can be treated by brushing the tongue twice a day with a toothbrush and maintaining good oral hygiene.
Teething troubles
Teething pain is common at two stages of life: when the first infant teeth come through, usually at around six months (although it can be earlier or later), and when the wisdom teeth come through between the ages of 17 and 25.
In babies, the bottom front teeth usually come through first, followed by the top front teeth; the teeth then come through gradually, until the back set – the second molars – come through at around 20-30 months.
Some babies have very few symptoms during teething, while others experience pain and discomfort. Common teething symptoms include:
• a slightly raised temperature (not a fever)
• flushed cheeks
• reddened gums
• dribbling or chewing
• poor appetite
• disturbed sleep.
The parents will usually know if these symptoms are normal; if they are not, you should refer the parent to the pharmacist, as many of these symptoms could indicate something more serious.
A range of gels is available to sooth infants while teething. You should make sure you recommend a product that is specifically for teething, and not a general oral pain relief gel, as these products are not suitable for babies. A pain relief product, such as a paracetamol or ibuprofen suspension, can also be recommended to treat pain. Always check the infant doesn't have sensitivity to anaesthetic before recommending a product.
Another solution is to give the baby something hard to chew on; in fact, chewing is a sign the baby has started teething. Good things to get an infant to chew on include raw vegetables, such as carrots or apple, or a teething ring. Teething rings can be cooled in the fridge (never the freezer) to help ease discomfort.
Wisdom teeth break through when most people are between 17 and 25, causing mild discomfort. Adults have four wisdom teeth, although some people never develop them or they never come through; this is called impacted teeth. Generally, dentists only recommend wisdom teeth are removed if it is causing pericoronitis, a recurrent infection requiring antibiotics, or if the tooth is damaging surrounding bone and teeth.
Customers looking for relief from wisdom tooth pain if there is swelling or infection can use a medicated mouthwash. A hot salt water mouthwash is also a good option.
Pain attributed to wisdom teeth can be caused by other reasons, such as dental abscesses or cysts (which require a dentist), or joint pain linked to stress (which is usually worse in the morning, because the customer has been grinding their teeth at night).
Loose crowns
If a customer comes in with a loose crown or filling, you should recommend an emergency dental repair kit.
If you don't have any available, take the following steps:
• Clean the inside of the crown with a tissue
• Replace the crown to check the teeth still bite correctly
• Remove the crown, and put some sugar-free chewing gum inside
• Dry the tooth with tissue or cotton wool, and replace the crown
• Get the patient to bite down to secure the temporary filling.
The patient should see their dentist as soon as possible, and in the meantime they should avoid sticky foods and not eat directly on the affected tooth.
Are electric tooth brushes better?
Any toothbrush will be able to clean teeth and prevent gum disease if used effectively. However, most people do not have a good brushing technique, and an electric tooth brush is likely to clean teeth more thoroughly, avoid gum damage, and get to hard-to-reach areas. The most effective types are oscillating brushes, where the head turns in both directions.
As bristles are hard, adult electric tooth brushes are not recommended for children. However, electric toothbrushes with soft bristles are available for children and can help if they have difficulty brushing their teeth with a normal toothbrush.
Key points
• Good tooth brushing technique is an important part of oralcare, and will help prevent cavities and gum disease.
• Any type of brush is effective, but as most people have poor technique, electric toothbrushes can be useful.
• Teething pain is common, and the parent will know what is normal for the child. You can recommend a product designed for teething, or suggest giving the child something to chew, such as an apple or carrot.
• Black hairy tongue is a scary condition, but it is harmless and can be treated with good oralcare.
Evaluation
• What oralcare options are available in your pharmacy? What are their ingredients, and who are they suitable for?
• Which gels are suitable for teething infants?
• Practice correct brushing technique in a mirror to see how it's done. Are you able to pass on your knowledge to a patient unsure how best to brush their teeth?
