A Healthy Mouth for a Lifetime: Beyond the Basics

Transcription

A Healthy Mouth for
a Lifetime: Beyond
the Basics
Dental Health Initiative of
San Diego/Share the Care
Acknowledgements
Materials compiled, written and edited by:
Andrea Bain, RDH, BS
Dental Health Educator, Dental Health Initiative of San Diego/Share the Care
Shannon Crosby, BS
Nancy Starr, RDH, MPH
Susan Stewart, RDH, EdD
Project Manager, Dental Health Initiative of San Diego/Share the Care
Margaret Wing-Peterson, MS, RD
Program Nutritionist, Dental Health Initiative of San Diego/Share the Care
Graphic illustrations, character designs and layout by:
Laurel Latto, DonnaBellas
Michael Nicholas, Michael Nicholas Graphic Design
We are grateful for the contributions of our reviewers:
Carolyn Walker, RN, PhD, San Diego State University School of Nursing
Peggy Yamagata, RDH, MEd, Program Manager Dental Health Initiative of San
Diego/Share the Care, County of San Diego Health and Human Services Agency
Much appreciated are the efforts of:
Irene Linayao-Putnam, Director of Health Promotion, the Union of Pan-Asian
Communities, who provided us with focus group interviews.
Student members of the San Diego State University Pre-Dental Club, who provided
us with focus group interviews.
Advisory Board of the Dental Health Initiative of San Diego/Share the Care whose
interest, support, and advice helped make this project possible.
This information was developed by San Diego State University Foundation’s Dental
Health Initiative, under contract to the County of San Diego Health and Human
Services Agency’s Maternal, Child, and Family Health Services Dental Health
Initiative. The project was supported in part by H47MC00004 for the Department of
Health and Human Services, Health Resource and Service Administration, Maternal
and Child Health Bureau and the State of California Department of Health Service
Material and Child Health Branch.
©2004 DHI/Share the Care
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These materials are support for a series of community oral health education guides
developed by the Dental Health Initiative of San Diego/Share the Care. The
information found in this section is designed to enhance and strengthen the materials
found in the various guides:
A Healthy Mouth for a Lifetime: Oral Health for Everyone contains oral health and
nutrition information geared toward school-age and adult learners and includes a set
of 12 lessons with activities for classroom environments.
Oral Health and Arts and Crafts: A Guide for Leaders Working with Children
incorporates oral health and nutrition messages into ten arts and crafts projects
designed for audiences pre-school age and older.
Dental Health Ambassador Training Manual guides instructors over eight sessions to
teach participants to become Dental Ambassadors who impart dental health
messages to various audiences.
For more information, contact:
Dental Health Initiative of San Diego/Share the Care Program
County of San Diego Health and Human Services Agency
P.O. Box 85222, M.S. P511-H
San Diego, CA 92186-5222
Phone: 619.692.8858
www.sharethecaredental.org
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A Healthy Mouth for a Lifetime: Beyond the Basics
Table of Contents
Acknowledgements……………………………………………………………………
Table of Contents……………………………………………………………………...
Introduction……………………………………………………………………………..
Why Good Oral Health is Important…………………………………………………
Oral Health is Linked to Overall Health……………………………………………..
Dental Basics…………………………………………………………………………..
Primary Teeth………………………………………………………………………
Permanent Teeth………………………………………………..…………………
Dental Disease: Cause………………………………………………………………..
Dental Caries (Tooth Decay or Cavities)………………………………………..
Periodontal (Gum) Disease……………………………………………………….
Oral Care and Special Considerations for Various Groups……………………….
Infants……………………………………………………………………………….
Toddlers…………...………..…………………………………………………..…..
School-Age Children……...………………….……………………………………
Teens………………………………………………………………………………..
Adults………………………………………………………………………………..
Pregnant Women…………………………………………………………………..
Older Adults………….……………………………………………………………..
People Who Wear Dentures……………………………………………….……..
The Tools of Tooth Care……………………………………………………………...
Toothbrushes……………………………………………………………………….
Power-Assisted Toothbrushes……………………………………………………
Toothbrush Adaptations…………………………………………………………..
Toothpaste...………………………………………………………………………..
Floss…………………………………………………………………………………
Tongue Cleaners…………………………………………………………………..
Special Treatments for Oral Care……………………………………………………
Dental Sealants…………………………………………………………………….
Fluoride Varnish…..………………………………………………………………..
Xylitol………………………………………………………………………………..
Tooth Whitening……………………………………………………………………
Common Causes and Consequences of Dental Trauma…………………………
Safety Gear…………………………………………………………………………
Treating Dental Emergencies……………………………………………….……
What Should be in a Dental First Aid Kit………………………………………...
Food Choices for Good Oral Health: The Basics…………………………………..
Food Choices for Good Oral Health for Various Groups…….……………………
Pregnant Women………………………………………………………………….
© 2004 DHI/Share the Care
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Infants……………………………………………………………………………….
Toddlers……………………………………………………………………….……
School-Age Children..……………………………………………………………..
Teens………………………………………………………………………………..
Adults………………………………………………………………………………..
Older Adults………………………………………………………………………...
Other Factors Affecting Oral Health………………………………………………....
Tobacco……………………………………………………………………………..
Alcohol………………………………………………………………………………
Tobacco and Alcohol Use: Oral Cancer Links…………….……………………
Prescription/Over-the-Counter Drugs……………………………………………
Xerostomia……………………………………………………………………...
Recreational or “Street” Drugs………………………………………….………..
Herbal Remedies…………………………………………………………………..
Oral Embellishment………………...……………………………………………...
Cultural Competence and Oral Health Education…....…………………………….
Asian, Pan-Asian, Pacific Islander……………….………………………………
Chinese………………………………………………………………………….
Hmong…….…………………………………………………………………….
East African.………………………………………………………………………..
Latino.……………………………………………………………………………….
Middle Eastern.…...……………….……………………………………………….
Arab……………………………………………………………………………...
Egyptian…………………………………………………………………………
Iranian…………………………………………………………………………...
Muslim….……...…….……..………..……………………………………………..
Native Americans………………………………………………………………….
Pakistani and Indian..……………………………………………………………..
Cultural Competence Summary…..…….………………………………………..
References……………………………………………………………………………..
General Resources……………………………………………………………………
© 2004 DHI/Share the Care
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Introduction
A Healthy Mouth for a Lifetime:
Beyond the Basics supports
discussion and learning activities
addressing good oral health beyond
the basic information in the
publication, A Healthy Mouth for a
Lifetime: Oral Health for Everyone.
“…Beyond the Basics” includes
information about topics, techniques
and products that address the oral
health of individuals from infancy through adulthood. It is a resource to help the
educator teach intermediate-level oral health information within families and
communities. In addition, it can serve as a reference for the Dental Health
Ambassador training program.
A Dental Health Ambassador is a person who promotes good oral health and
provides oral health education in the community. “…Beyond the Basics” can help
train Ambassadors to be dental health resources for individuals, including
parents and older adults. The text can also be used as support materials for the
Ambassadors in their community education efforts. The order of topics in A
Healthy Mouth for a Lifetime: Beyond the Basics has been designed to follow
curriculum order in the initial Dental Health Ambassador Training Manual.
Why Good Oral Health is Important
The Surgeon General’s Report
“Oral health means much more than healthy
teeth,” asserted the U.S. Surgeon General,
David Satcher, M.D., in the first-ever report
on the state of oral health in America, in June
2000. According to the report, the mouth is a
mirror of general health and well-being and
oral health is integral to total health. The
report notes that consequences of oral
diseases worsen over time if left untreated
and can affect one’s speech, appearance,
and self-esteem. Oral disease can harm a
person’s economic productivity and ability to
work at home, at school, or on the job.
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Significant findings include:
• Dental caries (tooth decay) is the single most common chronic childhood
disease, 5 times more common than asthma.
• More than 51 million school hours are lost in the U.S. each year to dentalrelated illness.
• Children cannot concentrate on schoolwork nor can adult workers pay
attention to job duties if they are in pain from dental disease.
• Employed adults in the U.S. lose more than 164 million hours of work
each year because of dental disease or dental visits.
Oral Health is Linked to Overall Health
Research shows a possible relationship between the
bacteria that cause dental disease and chronic
diseases/acute illness. For example, scientists have
noted a link between periodontal (gum) disease and preterm, low birthweight (PTLB) infants. Quite possibly, the
bacteria active in periodontal disease and the body’s
reaction to that infection trigger the release of the
hormones responsible for labor.
Furthermore, oral disease appears to impact:
 Heart Disease
 Stroke
 Diabetes
 Pneumonia
Dental Basics
Formation and Function
Development of the mouth begins when the human embryo is about three weeks
old, perhaps before the woman even knows she is pregnant. The first signs of
teeth in the embryo appear at six weeks of the pregnancy. At this time, the
embryo's tooth buds have begun to form. These buds start to mineralize or
harden between weeks 9 and 12 of the pregnancy.
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Primary (“baby”) teeth usually start erupting between
six and ten months of age. Central incisors (the front
middle teeth) usually come in first. The next teeth
appear on either side of the central incisors and
progress toward the back of the mouth, to the second
molars. Most of the primary/baby teeth should be
present by the child’s third birthday. A complete set
will have 20 baby teeth.
Primary Teeth
Upper Teeth
Erupt
Shed
Central Incisor
Lateral Incisor
Canine (cuspid)
8-12 mos.
9-13 mos.
16-22 mos.
6-7 yrs.
7-8 yrs.
10-12 yrs.
First molar
Second molar
13-19 mos.
25-33 mos.
9-11 yrs.
10-12 yrs.
Second molar
23-31 mos.
10-12 yrs.
First molar
14-18 mos.
9-11 yrs.
Canine (cuspid)
Lateral Incisor
17-23 mos.
10-16 mos.
9-12 yrs.
7-8 yrs.
Central Incisor
6-10 mos.
6-7 yrs.
Lower Teeth
Although primary/baby teeth are eventually lost, they play an important role in a
child’s normal growth and development:
•
Primary Teeth –
Crucial for:
• Place holding
• Speech
• Eating
• Face shape
• Appearance
• Self-esteem
•
•
They are crucial to speech development, nutrition,
formation of face shape, appearance and self-esteem.
They serve as placeholders for permanent (“adult”)
teeth, as they guide the new teeth into proper position.
Early tooth loss can lead to shifting of teeth, resulting in
crowding.
3
Primary/baby teeth begin to fall out at about age six years and are replaced by
the permanent teeth. At approximately the same time, the first permanent molars
erupt behind the last primary molar. A complete set of permanent teeth will have
32 teeth. All permanent teeth are usually in place by age 21 years but continue
developing their roots until a person’s late 20s. Teeth are meant to last a lifetime.
Like the primary teeth, the permanent teeth are vital for speech, nutrition,
appearance and self-esteem.
Permanent Teeth
Upper Teeth
Central Incisor
Erupt
7-8 yrs.
Lateral Incisor
8-9 yrs.
Canine (cuspid)
11-12 yrs.
First premolar (first bicuspid)
10-11 yrs.
Second premolar (second bicuspid)
First molar
10-12 yrs.
6-7 yrs.
Second molar
12-13 yrs.
Third molar (wisdom tooth)
17-21 yrs.
Lower Teeth
Third molar (wisdom tooth)
Second molar
17-21 yrs.
11-13 yrs.
First molar
6-7 yrs.
Second premolar (second bicuspid)
First premolar (first bicuspid)
11-12 yrs.
10-12 yrs.
Canine (cuspid)
Lateral incisor
Central incisor
9-10 yrs.
7-8 yrs.
6-7 yrs.
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Dental Disease: Cause
Dental Caries (Tooth Decay or Cavities)
Tooth decay is the most common chronic disease in childhood. Yet, according to
the U.S. Department of Health and Human Services/National Institutes of Health
in 2000, 25% of low-income children have never seen a dentist before starting
kindergarten.
Many parents do not realize that:
• People are not born with the
germs that cause cavities.
• Dental decay is an infectious
disease that can be spread to
the baby by the primary
caregiver, usually the mother.
• The more cavity-causing
bacteria in the primary caregiver’s saliva, the greater the risk of spreading
the bacteria to the child.
• Infection occurs anytime from approximately birth to four years of age.
Plaque is the sticky, colorless film that holds the disease-causing bacteria on
teeth and gums. Plaque contains live bacteria, their food and their waste
products. Streptococcus mutans is the chief bacteria that cause tooth decay.
The “Strep mutans” is passed between persons usually through saliva and can
occur when the caregiver:
• shares eating and/or
drinking utensils with Baby,
• cleans pacifiers in his/her
mouth,
• shares toothbrushes,
• pre-chews food for Baby,
• taste-tests the temperature
of Baby’s food, or when
• Baby puts fingers in the
caregiver’s mouth and then
back into own mouth.
Caregivers should keep their mouths as healthy as possible, to reduce the risk of
passing on dental disease.
Tooth decay usually first appears as chalky white spots on upper front teeth.
Caregivers should lift up the child’s upper lip to inspect the front and back of
those teeth and call the dentist if suspicious white spots are seen.
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Periodontal (Gum) Disease
Periodontal disease is a leading cause of tooth loss in adults. Plaque bacteria left
above and below the gumline are the main source of the infection. In its early
stages, periodontal disease is usually painless.
Periodontal disease is divided into two main categories: “gingivitis” (reversible
inflammation of the gums) and “periodontal disease” (treatable but irreversible
breakdown of the supporting structures of the teeth.)
Gingivitis is the earliest stage of gum disease. Signs and symptoms can include
red, swollen, tender, and/or bleeding gums. At this point, gingivitis is reversible
with professional cleaning, improved home care and a
Gum disease:
good diet. Regular dental visits are essential to maintain
initially painless,
healthy gums; the dental professional can assess gum
but the leading
health, treat problem areas early, remove plaque and tartar
cause of tooth
(calcified plaque) above and below the gumline and
provide education.
loss in adults
Left untreated, gingivitis can progress to periodontal disease. Periodontal
disease is advanced gum disease that involves the bone and ligaments
surrounding the teeth. The gum disease
has moved into these tooth-supporting
tissues, and as bone destruction
continues, pain often follows. As the
disease progresses, more bone is lost.
Pus may develop, and teeth might
loosen or even fall out. The disease
itself is treatable, but the body cannot
grow the bone back naturally. A dental
professional should check for
periodontal disease at least annually. If
disease is present, treatment will depend on the type and extent of damage.
Treatment methods can include scaling and root planing to remove bacterial
deposits above and below the gumline, prescription medication and rinses, and
periodontal surgery. Special techniques have been developed to stop the bone
loss and are used by some dental specialists.
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Gum disease can happen to anyone. Risk factors play a role,
but for the most part, the infection can be avoided. Most adults
show signs of gingival or periodontal diseases, and 14% of
adults aged 45-54 and 23% of
Possible Risk Factors
65-74 year olds experience
for Gum Disease:
severe periodontal disease.
• weakened immune
system
Dental disease is preventable
with effective daily oral hygiene,
• family history
dental visits every six months or
• chronic health
as recommended, a diet of healthful foods, and
conditions, such as
the use of fluoride and sealants to strengthen
diabetes
teeth and prevent cavities.
For additional information on tooth anatomy and function, see A Healthy Mouth
for a Lifetime: Oral Health for Everyone, pages 1.1 to 1.3.
Oral Care and Special Considerations
for Various Groups
Infants
Oral care should start as soon as Baby is born.
Whether nursed or bottle-fed, the infant should have
his/her mouth wiped after each feeding with a clean,
damp washcloth or gauze. First teeth usually appear
around age six months. Once they erupt, the teeth
should be brushed with a small, soft toothbrush, using
gentle, circular motions. Do not scrub. All surfaces of
the teeth should be cleaned; no toothpaste is needed.
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In addition to the standard toothbrush shape, several other types of toothbrushes
are available for infants. A finger brush slips over the caregiver’s entire index
finger and has soft bristles on its end. It can be used to clean or massage gums
and brush first teeth. Other brushes are shaped like teething rings but have soft
bristles attached to one side. Make sure that:
 bristles are soft,
 the brush head fits Baby’s mouth and
 the caregiver can use the brush to reach all areas of Baby’s mouth.
Baby’s bottle should provide only breast milk,
formula or water. Baby should never be allowed to
go to sleep with a bottle of sugar-containing liquid,
including milk. This allows sugars to collect around
the teeth and cause cavities. “Nursing caries” form in
the same way if Baby is allowed to sleep with mother
and nurse at will throughout the night.
A cup for drinking should be
introduced to Baby starting at age six
months. Use of a bottle should be
stopped by age one year. Pacifiers
should not be dipped in anything
before giving it to Baby.
A baby’s first dental visit should take place by age one year. At the visit:
 the dental professional can examine the development of the child’s mouth,
 the caregivers can ask questions about
how to care for baby’s mouth and
 a comfortable dentist-patient partnership
can develop for the whole family.
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Toddlers
Oral care remains the responsibility of the caregiver:
 Clean teeth at least twice a day with a small, soft-bristled toothbrush,
preferably after the morning meal
and before bedtime.
 Use a fluoride-containing toothpaste
only if the child can spit it out when
directed, or a dental professional has
recommended its use for the child.
 When fluoride-containing toothpaste
is recommended, use only a small pea-sized amount. Toothpaste should
be stored out of toddlers’ reach.
 Start to floss when two teeth touch side-by-side. Floss once a day.
Healthful snacks such as vegetables and fresh fruits should be included in the
toddler’s diet. Foods low in sugar but high in flour, such as crackers or dry
cereals, can cause cavities if eaten
alone as snacks. By now, the child
should be using only a cup for drinking.
However, the toddler should not be
allowed to carry a cup of sweetened
beverage to drink at will throughout the
day, as this can encourage cavities to
form.
Thumbsucking or pacifier use should be gradually
reduced as the child gets older, with the practice
stopped by age four years. A dental professional is
a good resource to consult if a caregiver has
concerns about thumbsucking/pacifier use.
Visits to the dentist should be scheduled every six
months for the toddler, or as directed by the dental
professional. Caregivers should discuss with the
dentist whether the child needs fluoride
supplements.
School-Age Children
Oral care is the joint responsibility between the child and caregiver. Not until
around age eight years does the child have enough hand coordination to be able
to brush and floss effectively. The caregiver needs to supervise and encourage
proper technique so that healthful habits can be continued:
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•
•
•
brushing with an appropriate-sized, softbristle toothbrush at least
twice a day,
using a small pea-sized amount of
toothpaste with fluoride to help
strengthen tooth enamel and resist
decay, and
flossing at least once a day.
Flossing can be difficult for a
school-aged youngster
because of the required hand coordination. The child might
insist on doing it alone, but caregivers should at least
supervise the process and can ask the dental professional to
check the technique for effectiveness.
Dental sealants help protect the chewing surfaces of
teeth from cavities. This special plastic is applied to premolars and molars before the teeth can decay.
Caregivers should ask about these at the dental office.
Dental injuries are a major cause of tooth loss in
this age group. Caregivers should insist their
children wear mouthguards and other safety equipment while playing sports
and riding recreational equipment such as scooters and bicycles.
Protect teeth for
school-age youngsters
with
• brushing and flossing
• fluoride
• dental sealants
• safety gear
• healthful foods
Like younger children, school-age youngsters
continue to need healthful snacks such as
vegetables, fresh fruit, low-fat cheese and other lowfat dairy products. These items are potentially less
harmful to teeth than high-sugar, high-starch items
and contain nutrients needed for normal growth and
development.
Actions that caregivers can take include:
• encouraging children to make good decisions
about their food choices,
• modeling these practices by choosing foods
wisely themselves and
• having healthful foods readily available at home
to reinforce these messages.
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Teens
Teenagers are frequently interested in their
overall appearance and social acceptance. This
interest can help provide motivation for good oral
health habits that produce cleaner teeth,
healthier gums and fresher breath.
• Brushing teeth and tongue at least twice daily
with a soft-bristle brush
• Flossing at least once daily
• Toothbrushing with a pea-sized amount
fluoridated toothpaste
• Regular visits to a dental professional
Good oral hygiene is essential; normal hormonal changes of adolescence make
teens more susceptible to gingivitis.
Healthful foods such as low-fat dairy products, fruits and vegetables promote
good oral health and are good choices for between-meal eating. Encourage milk
consumption at meals and water between meals; minimize use of sodas, both
regular and diet. Mouth guards and safety equipment should be used for sports
and recreational play.
Tobacco use must be discouraged even though peer pressure and popular
culture make it appealing. Tobacco use is a major cause of oral cancer. The
teenage user must see a dental professional regularly and inform the health
provider about the tobacco habit so that oral cancer screenings can be
performed routinely. The teen should also learn how to do a self-exam for oral
cancer and perform this monthly.
Teens are prone to eating disorders such as bulimia
nervosa or anorexia nervosa. Vomiting as a method of
bulimic purging causes tooth erosion, or loss of minerals
from tooth enamel, due to the acidic stomach contents.
When working with individuals, encourage them to rinse
the mouth with water immediately after vomiting. They
should then wait at least 30 minutes before brushing
teeth to minimize further harm to tooth enamel. General
malnutrition can develop from the bulimia or anorexia,
and will further affect the general health of the mouth tissues.
Teens need to continue regular dental visits. If the teen did not receive dental
sealants at a younger age, the sealants can still be applied. The dental
professional will make this decision and also check the condition of any
previously placed sealants.
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Adults
Oral care for adults is a continuation of the good patterns started earlier in life.
• Toothbrushing twice daily with a soft-bristle brush and a pea-sized amount
of fluoridated toothpaste
• Flossing once a day
• Regular check-ups with a dental
professional
Adults should consider themselves to be role
models of good oral health and self-care for
their children, grandchildren and other
youngsters with whom they interact.
Healthful foods should be the core of the diet.
Minimize added sugars such as those in
cereals, sodas, and blended coffee drinks.
Vegetables and fresh fruits help promote good
oral health and can help reduce risks for
chronic diseases such as cancer.
Tobacco users should ask their dental professional how to perform a self-exam
for oral cancer and complete the exam monthly.
Pregnant Women
Regular dental visits are a part of good
prenatal care. An expectant mother should
check with the dental professional to schedule
needed visits. Poor oral health during
pregnancy has been linked to a greater
likelihood of early labor/delivery and low
birthweight newborns.
Pregnant women often experience swollen
and/or bleeding gums due to normal hormonal
changes; this is often called “pregnancy
gingivitis.” Expectant mothers must maintain exceptionally good oral hygiene
throughout their pregnancies.
Morning sickness and acid reflux are common occurrences. Acid from stomach
contents can cause tooth erosion. After vomiting, the woman should rinse her
mouth with water and wait at least 30 minutes to brush her teeth, to minimize
further harm to tooth enamel. An over-the-counter fluoride mouth rinse is often
recommended for use after vomiting to help re-mineralize and re-strengthen
tooth enamel.
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Unfortunately, many women choose
crackers, toast or other foods high in flour to
ease their nausea. These foods leave sticky
bits on teeth that promote the growth of
cavity-causing bacteria. Food debris should
be removed immediately by rinsing with
water or by eating wet, crunchy foods such
carrots or apples.
Older Adults
In the past, many older
About 30% of
adults expected to lose
adults 65 and
their teeth and wear
older no longer
dentures. Now, through
have their
heightened awareness
and preventive care,
natural teeth.
adults are able to keep
their natural teeth. By continuing the wellestablished practices of brushing twice
daily, flossing once daily, and visiting the
dental professional routinely, teeth can
last a lifetime.
Many people mistakenly believe adults no longer need fluoride. However, many
adults, often without their knowledge, have gingival recession (receding gums)
that exposes the root surfaces of their teeth. The strong enamel layer on the
crowns of teeth does not cover root surfaces. Instead, root surfaces are covered
by cementum, which is much weaker than enamel and is more likely to decay. To
protect root surfaces from cavities, a pea-sized amount of fluoridated toothpaste
should be used routinely in toothbrushing. Older adults should ask the dentist if
additional fluoride is recommended.
Older adults should continue with healthful food practices while reducing added
sugars. Nutrient-rich snacks, low in fat, calories and sugar, should be part of the
daily diet.
Older adults should check with the dentist for instructions on completing an oral
cancer self-exam. The self-exam should be performed monthly. This is
particularly important for tobacco users.
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People Who Wear Dentures
People who wear dentures or removable partial dentures
have specific oral hygiene needs. Recommendations
include:
• Rinse with water after every meal
• Clean dentures or partials daily by removing and
rinsing them with water, then brushing them with a
soft brush or denture brush and toothpaste.
• During cleaning, protect dentures from breaking or
cracking by washing them over a sink partially
filled with water.
• For additional safety, line the sink with a washcloth or small towel to
cushion the fall should the dentures drop.
• Denture cleansing solutions can be used to clean dentures or partials for
added benefits. Never soak dentures or partials in bleach as this damages
the color.
• Brush gums, tongue and existing teeth at least twice daily.
• Check with a dentist for specific guidelines on how long dentures should
be left out of the mouth each day. Gums need to “breathe” every day to
help avoid irritation and infection.
• See a dentist at least yearly to be certain the dentures fit properly and to
be screened for oral cancer. The dentist can also answer questions about
specific dietary needs.
For more on toothbrushing and flossing techniques, see A Healthy Mouth for a
Lifetime: Oral Health for Everyone, pages 2.3.2 to 2.3.3 and 2.4.1 to 2.4.2
The Tools of Tooth Care
Toothbrushes
The earliest known toothbrush dates back to about 5,000 BC. Through the years,
they have evolved, first being plant roots,
then hog bristles and now the rounded
nylon bristles. When selecting a toothbrush,
choose one with soft nylon bristles. Avoid
natural bristle brushes, their hardness
cannot be controlled, and their hollow shaft
can harbor bacteria.
14
The size of the toothbrush head depends on the size of the mouth to be cleaned.
Choose a toothbrush that will give easy access to all areas of the mouth,
including behind the last molars. Consult a dental professional regarding
individual needs.
Toothbrushes should be replaced at least every three months, or when bristles
are splayed or bent. Bristles wear out over time and do not clean as effectively.
Bent or splayed bristles are ineffective at cleaning and might indicate the use of
too much pressure, especially if this
occurs in less than three months of use.
Toothbrushes should be replaced after an
illness such as cold, flu, or strep throat.
Bristles can harbor germs that can reinfect a person with the same illness.
Power-Assisted Toothbrushes
Power-assisted (“electric”) toothbrushes have
been available for many years. They are an
alternative or an addition to manual
toothbrushes. The design has been improved
over time, and many choices are now available.
A power-assisted toothbrush can be a great
benefit for individuals with limited manual
dexterity or for children to make brushing fun.
The basic parts of a power-assisted brush
include the handle, the brush head and the
power source. Most handles of power-assisted
brushes are thicker and heavier than those of
manual brushes. Brush heads vary in size and
shape; again, the best size would provide easy
access to all areas of the mouth for cleaning.
Some brush heads are removable and should be
replaced according to the recommendations of
the dental professional.
Several different motions of the brush head are available.
One motion is “rotational,” where the bristles move in a
circular, clockwise motion.
A “counter-rotational” motion involves two brush heads, one
moving in a clockwise direction, the other moving counterclockwise.
15
An “oscillating” brush head moves with a sweeping, back-andforth motion.
A “sonic-wave” brush emits sonic waves that vibrate and disturb the
bacteria along with the vibrating movement of the bristles
themselves.
The toothbrushes can have a variety of power sources. “Battery operated”
products might have replaceable batteries. With “rechargeable” brushes, the
base is plugged into a wall electrical outlet and the toothbrush recharges while
sitting on the base.
Power-assisted brushes also differ in the types of power switches. Some have a
switch that must be continuously pressed to get power; persons with limited hand
strength might have trouble keeping the brush “on” consistently. Other models
have a switch that needs only to be turned on, and the brush stays on by itself. In
addition, some models have a built-in timer to indicate 30-second intervals.
Whether a manual or electric toothbrush is used, it is still important to brush with
the proper technique for at least two minutes, twice a day. Brush heads on
power-assisted toothbrushes should be changed regularly, according to the
dental professional’s advice. The dental care provider can also provide
information about brush models that are most beneficial for the individual.
Toothbrush Adaptations
Power-assisted toothbrushes are not the only option for persons with physical
limitations. With simple adaptations, manual toothbrushes can be used. Health
professionals and other caregivers should assess the brushing abilities of
persons with special needs. Toothbrush adaptations are recommended for those
with limited arm strength, weakened grip, limited range of motion, restricted
ability to open their mouths or reduced muscle coordination.
Factory-modified toothbrushes can be purchased at a
pharmacy or some general merchandise stores.
However, simple, inexpensive changes can be made
at home to lengthen, widen or bend standard manual
toothbrushes to facilitate regular brushing. A
toothbrush handle can be lengthened by securely
taping two wooden tongue depressors onto the
handle, or, the head of a new or used toothbrush can
be cut off and the remaining handle, securely taped to
the handle of a second brush.
16
To give the handle more bulk and make it easier to
grasp, a toothbrush handle can be inserted into a
standard bicycle handlebar grip or into a hole made in a
tennis ball or racquetball. An adaptation with a smaller
diameter can be made using a small, frozen juice
container: remove the top of the container and insert a
racquetball that has had a hole cut into it. Then, insert
the toothbrush handle into the hole. The individual now
grasps the juice container, not the racquetball.
If an angled-head toothbrush cannot be purchased or if it does not meet the
individual’s needs, a standard toothbrush handle can be bent permanently to
allow easier access to some areas of the mouth. Run hot tap water for about a
minute over the brush’s neck (where the brush head and handle meet) until the
plastic becomes pliable and can be bent into the desired angle.
Some persons might have uncontrollable bite
reflexes or not be able to hold their mouths
open. A mouth prop can be used to keep the
mouth open and prevent accidental bite
injuries. For a simple but effective prop, tightly
roll a moistened washcloth and then insert it
between the upper and lower jaws. Or, an
inexpensive mouth prop can be created by
stacking four to six wooden tongue depressors,
binding them together with masking tape, then
wrapping them with gauze, to serve as a cushion
upon which to bite.
Toothpaste
Toothpaste is not needed to clean teeth, but it
makes the task more pleasant. If the toothpaste
contains fluoride, it can also help strengthen
tooth surfaces, therefore, reducing the risk of
tooth decay. Fluoride-containing toothpaste
should not be used with children who cannot spit
it out upon command, unless a dental professional
has recommended otherwise.
Did you know…
…Like dental extractions, use of
toothpaste is ancient. The
earliest mixtures were made
from powdered fruit, talc, and
burnt shells, perhaps
sweetened with honey and
flavored with lizard livers,
mouse parts and urine…?
Fluoridated toothpaste contains concentrated
fluoride, a natural mineral that helps teeth resist
decay. The amount in the toothpaste is meant as
a topical (surface) fluoride treatment for teeth and
is not meant to be eaten. A small pea-sized
17
amount of toothpaste contains enough fluoride to affect the tooth enamel directly.
A child who repeatedly swallows the toothpaste is at risk for depositing too much
fluoride into developing teeth. Excess fluoride can cause white spots in enamel, a
condition known as dental fluorosis.
The American Dental Association (ADA) Seal of
Acceptance on the product package indicates some
product claims have been reviewed, tested and verified.
Seals should be read for each claim on the package.
Consult a dental professional regarding the need for
toothpastes with specific ingredients, such as tartar
control agents, baking soda or whitening agents.
Floss
Floss removes plaque between teeth more effectively than
a toothbrush and can clean below the gumline when used
properly. Caregivers should begin flossing children’s teeth
as soon as there are two adjacent teeth touching. Adults
should continue to take responsibility for flossing teeth until
the child has the hand coordination to do a good job,
usually about age eight years. Thereafter, caregivers
should supervise the use of floss to ensure its effective and
safe use.
Many types of floss are available. Floss can vary greatly in flavors, textures and
width, and comes both waxed and unwaxed. Research has shown no difference
in the effectiveness between these two types. Rather, plaque removal depends
on flossing technique. Individuals should follow their dental professionals’
recommendations regarding type and technique for flossing.
A floss holder can help those who have difficulty holding and moving the floss
properly with their fingers. Several types of reusable or disposable plastic floss
holders are commercially available. From time to time, patients should review
their flossing technique with the dental professional.
Tongue Cleaners
Tongue cleaning devices have been employed in many cultures world-wide for
hundreds of years. Tongue cleaners are used to remove bacteria and food debris
from the top surface of the tongue. The intent is to reduce the numbers of
bacteria and mouth odor. Present-day tongue cleaners, available over-thecounter in pharmacies and general merchandise outlets, can be made of plastic,
stainless steel or flexible metal. Tongue cleaning can also be accomplished by
simply brushing the tongue surface with a toothbrush during routine
toothbrushing.
18
Special Treatments for Oral Care
Dental Sealants
The first step in maintaining a healthy
mouth is preventing tooth decay.
Dental sealants can offer major
protection against cavities. A dental
sealant is a clear or white (opaque)
plastic material that is usually applied
to the chewing surfaces of premolars
and molars (the back teeth). It can also
be applied to the grooves in the cheek-side surfaces of molars. This plastic
sealant bonds into depressions and grooves (“pits” and “fissures”) of the chewing
surfaces of back teeth, which are prone to tooth decay.
The likelihood of developing decay in the grooves of back teeth begins early in
life. Children and teenagers are obvious candidates for sealants, but adults can
benefit from sealants, too. Toothbrush bristles cannot reach all the way into a
tooth’s depressions and grooves to clear out food and bacteria. Sealants act as
barriers, “sealing out” plaque, food and bacterial acid and protecting the
vulnerable areas in the enamel. Dental sealants are placed on teeth before they
have cavities. Sealants are normally placed on permanent premolars and molars.
However, they can be placed on primary teeth.
Dental sealants are easily applied, and state laws will indicate who can place
them. Only a few minutes are needed to seal each tooth, and no injections are
needed. First, surfaces of the teeth to be sealed are cleaned. Then the chewing
surfaces are “roughened” with a mild acid solution to help the sealant adhere to
the tooth. The sealant is then “painted” onto the tooth enamel, where it bonds
directly to the tooth and hardens or “cures.” Some sealants “air cure;” other
sealants are hardened with a special light.
Dental Sealants
• protect against
cavities
• easy to apply
• no injections
needed
• can last for
years
As long as the sealant remains intact, the tooth surface will
be protected from decay. Sealants hold up well under the
force of normal chewing and usually last several years
before needing to be replaced. During a regular dental
visit, the dentist can check the condition of the sealants
and reapply if necessary.
Even with sealants, brushing, flossing and regular dental
visits are important because sealants won’t protect
between teeth where cavities often develop. Sealants can
reduce cavities in molars by more than 50 percent, and can be especially helpful
in areas without fluoridated water.
19
Fluoride Varnish
Enamel can be remineralized or “healed”
by fluoride treatments and from the
natural minerals in saliva. Studies have
shown the healed areas are stronger than
the original enamel when fluoride is
available. Combining calcium, phosphate
and fluoride together produces a stronger,
acid-resistant layer overlying any
weakened areas.
Fluoride comes in many forms, including
varnish. This product has been used in
Europe for decades. It is now used in the
U.S. and is especially useful for young children to prevent early childhood dental
disease. Varnish helps reduce cavity-causing bacteria and strengthens enamel.
The thick, liquid fluoride varnish is painted onto all surfaces of teeth. The process
is painless and requires only a few minutes to apply. Teeth do not have to be
professionally cleaned before the varnish is applied, as compared to traditional
fluoride treatments.
Varnished teeth appear slightly yellow for
up to 48 hours. After the application,
eating or drinking should not be allowed
for 30 minutes. Only soft foods should be
given and toothbrushing should be
postponed for 24 hours, to give the
varnish maximum time to take effect.
Children as young as one year of age can
have the varnish applied to their teeth. It
should be reapplied, as recommended by
the dental professional.
Xylitol
• safe, natural
sweetener from
plants
• does not support
growth of cavitycausing bacteria
• helps reduce risk
of cavities
• in gums, candies,
medications
Xylitol
Xylitol (ZY- leh - tol), a naturally occurring
carbohydrate, appears to help reduce the
development of cavities. Xylitol is related to other
sugars in its chemical structure and provides a
sweet taste in foods and beverages. Studies have
shown that bacteria in plaque
cannot use the xylitol for food.
Therefore, the bacteria cannot
produce the acid waste products
seen when eating “regular”
sugars and starches. With xylitol,
20
the bacteria grow poorly and do not stick well to tooth surfaces, helping reduce
the spread of cavity-causing bacteria between children and their caregivers.
Xylitol has been used for many years in this country and abroad in foods for
diabetic persons, in patient tube feedings, and in medications for children. One of
the major bacteria that causes ear infections does not grow well with regular
exposure to xylitol. Therefore, repeated use of xylitol-containing products can
help reduce ear infections. Check with a healthcare provider for
recommendations on use for this type of illness.
The use of xylitol in sugarless chewing
gum appears to be effective in reducing
cavities. Long-term use of xylitolcontaining food products has been shown
to be safe. However, simply adding xylitol
to a food product that also contains
sugars/starches does not guarantee
freedom from cavities. Xylitol is most
effective in reducing dental disease if it is used in products that contain
ingredients that are “dental-safe” such as fiber or
artificial sweeteners such as aspartame.
Check food package
labels:
Costs for xylitol-containing products vary, depending
“No sugar:” NOT the
on the concentration of the xylitol. Higher
same as “no cavities”
concentrations are more costly and require a
Xylitol = reduced
prescription for purchase, as these are considered
chance of cavities
medications. Refer to a health professional for
dosage.
Tooth Whitening
Tooth whitening is a process used to
bleach or lighten the color of tooth enamel.
There are many methods and products
available to whiten teeth. Most often the
mixtures contain a form of hydrogen
peroxide called carbamide peroxide.
Not everyone is a candidate to have his/
her smile brightened. Tooth whitening is only temporary; tobacco, cola, tea,
coffee, red wine and some berries are just a few of the culprits that stain tooth
enamel. Continuing to use these items after whitening will stain the newly
whitened teeth. Prior to using any teeth whitening or “bleaching” products, an
evaluation by a dentist should be performed.
21
Whitening products can lighten only natural tooth
structures. Any “unnatural” teeth (such as those
covered with porcelain crowns) or teeth with
bonding (tooth-colored fillings) will not respond to
the whitening products. People with crowns and
bonding on front teeth (or on any teeth that are
visible in a smile) might not be candidates for
tooth whitening, as the crowns and bonding do not
always match the newly whitened, natural teeth.
Of course, new crowns and bonding can be
placed after the whitening process is completed.
Whitening Process
• over-the-counter
products used at home
OR
• professional products
used at the dentist’s
office OR
• professional products
used at home
The original shade or color of the teeth is another
consideration when deciding whether to whiten
teeth. Yellow shades tend to respond well to the
whitening process, whereas, grayish tones
typically do not. Results do vary between persons.
Individuals should discuss with the dentist whether
whitening is an option for them. Teeth can be
whitened through three main methods: treatments
in the dental office, take-home products dispensed
by the dentist, and over-the-counter products.
Treatments in the dental office are typically the most costly, but results are
achieved within one appointment (1–2 hours). A whitening gel is applied to teeth,
and then is activated by a special light.
Whitening can also be achieved with products that are
dispensed by the dentist and used at home. The dentist
makes a custom mouth tray to be used at home with a
concentrated whitening gel. The gel is placed in the tray
and worn several hours daily or nightly for an average of
two weeks. The amount of time depends on the product,
the frequency of use, and the enamel’s response. The
dentist might suggest short visits to monitor the progress of
the whitening process and to check the mouth for adverse
effects such as tooth sensitivity and gum tenderness.
Lastly, teeth can be whitened through the use of over-the-counter (OTC)
products including toothpastes, whitening strips, brush-on gels and whitening
chewing gum. The OTC whitening products might not provide the same results
as the professional strength products. As with the professional whitening
products, results can vary. Concerns or questions should be discussed with the
dentist.
22
Some side effects from both professional and OTC
whitening products might include:
 temporary tooth sensitivity, which is often
counteracted with fluoride applications,
 gum redness, and/or
 gum tenderness or irritation from the
whitening ingredient, peroxide.
Common Causes and Consequences of Dental Trauma
Mouth injuries, especially in children, occur from a variety of causes. These can
include falls, or chewing on hard objects such as ice, corn nuts, pencils or bottle
caps. Chewing on electrical cords can pose the threat of an electric shock and
burn, and in severe cases it can cause death. Many children involved in sports
are also at risk for dental injuries. Protective safety gear should be worn to help
prevent serious injury to the mouth or body.
Another cause of dental trauma is vehicle crashes. Children who ride in car seats
should be secured correctly, and parents need to be certain the car seat itself is
installed and secured properly. All passengers should wear seatbelts at all times.
Not only can dental trauma result in immediate pain, but it can also cause
permanent damage to teeth and supporting structures. Damage, such as tooth
discoloration, a broken root or pulp damage, might appear right away or take
several years to show up. In addition to pain and permanent damage, dental
injuries are costly to repair. All injuries should be checked by a dentist.
23
Safety Gear
Safety gear cushions and protects the body from serious
injuries, including concussions. Gear should be worn when
riding or using recreational equipment such as bicycles,
scooters, rollerblades and skateboards. Safety equipment is
also crucial when playing contact sports.




Football
Baseball
Hockey
Karate



Soccer
Softball
Basketball
Mouth guards are important in the protection of the
brain, not just the teeth. The amount of force that can
knock out a tooth is about the same amount needed to
cause a concussion. A well-fitting mouth guard can
protect against concussions because it will act as a
shock absorber to reduce the impact of blows to the
head.
Mouth guards can be custom-made by a dentist or
store-bought. Store-bought mouth guards come in two
varieties: one to be used, as-is, and the other, a “boil-and-bite” type, which allows
some personalizing for fit. Before using the “boil-and-bite” guard, the user must
first place it in hot water to soften it, then bite down on it so it takes on the
impression of the teeth.
The best-fitting mouth guard is custom-made in a dental
office after a professional impression is taken of the mouth.
Mouth guards for children should be replaced often as the
child grows and the size and shape of the mouth changes.
Since concussions can be life-threatening, safety helmets
are another vital protector. In order to be effective, a helmet
should fit snug with no sliding on the skull and should be
worn to cover the top of the head and forehead. The
chinstrap should be buckled snug but comfortably to prevent
the helmet from moving or coming off.
Other safety gear include wrist guards, elbow pads and
kneepads. These should fit snug and should be tried on
before purchasing to ensure proper sizing.
Mouth Injuries From
• Falls
• Chewing on ice
• Eating corn nuts
• Biting pencils
• Untwisting bottle
caps with teeth
• Chewing on
electrical cords
• Unprotected
contact sports
• Non-use of vehicle
seat belts
24
Treating Dental Emergencies
In the event of a dental emergency, quick thinking and fast action could make the
difference in saving a tooth or reducing the effects of an injury. The following is a
basic guide for giving dental first-aid in some common oral/dental emergencies:
Toothache -- Rinse mouth with warm water. If swelling occurs, apply
cold packs to the outside of the face. DO NOT apply aspirin or other
medications directly to the aching tooth. Go to a dentist for evaluation
and treatment.
Bleeding Gums -- If gums are red, swollen, or sore, rinse every
two hours with a mixture of equal parts of water and hydrogen
peroxide or with a warm salt water solution. If the condition does
not improve in a few days, see a dentist.
Broken Tooth -- Clean injured area with warm water.
If the injured area begins to swell, apply cold packs to the outside of
the face. See a dentist immediately.
Knocked-Out Tooth -- First, attempt to find the tooth. If possible,
place the tooth in milk or water. If the tooth is dirty, it can be gently
rinsed with water. DO NOT scrub it. Scrubbing can remove the
tooth’s natural fibers that could later help to reattach the tooth in the
socket. DO NOT wrap the tooth in tissue. The tissue will stick to the
tooth fibers, making it harder for the dentist to clean. If the tooth
cannot be located, it could have been knocked in or shoved into the
jaw, in which case it should not be touched. Whether the tooth is
knocked out or in, go to the dentist immediately.
Objects Wedged Between Teeth -- Carefully remove the object
from between teeth with dental floss. DO NOT remove sharp
objects. If it is not possible to remove the object or if the object is
sharp, see a dentist immediately.
Canker or Cold Sores and Fever Blisters -- For
temporary pain relief, apply an over-the-counter, mouthnumbing product that contains benzocaine, a numbing
agent. Use as directed on the product label. Avoid spicy, salty or acidic foods. A
non-aspirin pain reliever can be swallowed; the pill should not be applied directly
to sores. If the sores do not heal within 7-14 days, and/or signs of fever and pain
continue, contact a dentist.
Tongue or Lip Bite -- If bleeding occurs, apply pressure with a
clean cloth. If swelling occurs, apply a cold pack. If bleeding does
not stop or if the bite is severe, go to a hospital emergency room.
25
Broken Jaw -- If it is suspected the jaw is broken, DO NOT move the
jaw. Wrap a scarf, handkerchief, tie, or a towel around the head to
keep the jaw from moving and go to a hospital emergency room
immediately.
Pain From a New Tooth Appearing -- Find the site and apply a cold
pack to the outside of the face. An over-the-counter, non-aspirin
children’s pain reliever in pill or liquid form can be swallowed. The
medicine should not be applied directly on the gums. For temporary
pain relief, an over-the-counter, mouth-numbing product that
contains benzocaine, a numbing agent, can be applied directly on gums. Use as
directed on the product label. If pain continues, contact a dentist.
What Should Be in a Dental First Aid Kit
It is impossible to know when a dental
emergency will occur. But parents,
grandparents, caregivers, teachers, coaches,
and childcare providers can be prepared by
having on hand a basic dental first aid kit.
To make a simple kit, start with a large,
zippered, soft-sided pouch or a shoebox-sized
plastic container that has a secure lid. Then fill
it with the following supplies:
•
•
•
•
•
•
Cotton, cotton swabs, or sterile gauze - to clean injury
Dental floss, interdental cleaner, or toothpicks - to help remove objects from
between teeth
Dental wax, paraffin or candle wax - to place
on a sharp, chipped tooth to help reduce gum
and cheek irritation on the way to the dentist
Handkerchief, neck tie, or towel - to stabilize
or keep a broken jaw from movement on the
way to the emergency room
Instant ice pack – to help reduce swelling
A small box of “shelf-stable” milk – to carry a
knocked-out tooth to the dentist. Shelf-stable milk, packaged in lunch-box
sized foil-lined pouches for use away from home, does not need to be
refrigerated until after it is opened. Therefore, it can be stored in the first aid
kit. However, fresh milk can be used if it is available in the emergency.
26
Food Choices for Good Oral Health: The Basics
The presence of food in the mouth can
greatly increase the activity of cavitycausing bacteria. Foods that contain
carbohydrates as sugars or starch are the
preferred fuel for the bacteria, and promote
their growth and acid production. These
acids dissolve and weaken tooth enamel.
The longer this bacterial acid remains in the
mouth, the greater the damage to tooth
enamel.
The carbohydrates in food can be
naturally occurring, as in fruits and
milk, or might be added in
processing, as with pre-sweetened
cereals and crackers.
Carbohydrate-containing foods,
such as whole grains, milk, fruits
and vegetables, provide vitamins
and other valuable nutrients and are a part of healthful eating.
“Non-nutritive sweeteners” or artificial
sweeteners can be naturally occurring, such as
xylitol or sorbitol, or made from naturally
occurring substances, such as aspartame or
sucralose. Some are truly synthetic, such as
saccharin. If cavity-causing bacteria feed on
them at all, they do so slowly. The bacteria do
not grow and produce much enamel-dissolving acid. All are either free of calories
or contain very few calories. Therefore, reducing one’s sugar intake is one way to
reduce calories and cavities. However, heavy use of artificial sweeteners does
not always benefit health.
Xylitol has special qualities
that block growth of cavityforming mouth bacteria.
See page 20 in this manual
for more information.
For more detail about good food choices, see A Healthy Mouth for a Lifetime:
Oral Health for Everyone, pages 1.7-1.11.
27
Food Choices for Good Oral Health
For Various Groups
Healthful food choices promote the health of the whole body, not just in the
mouth. Food contains the nutrients required for:
• normal growth and development;
• maintenance of body structures such as
blood cells, bones and muscles; and
• body functions such as vision and
movement.
Wisely selected, foods provide substances that can help reduce the risks for
health problems such as heart disease, stroke or cancer. Throughout the life
span, a well-chosen diet will promote good oral health and good overall health.
Pregnant Women
The expectant mother should eat foods rich in the nutrients
that support normal growth and development, including
protein, calcium and folic acid. Folic acid helps to reduce
birth defects such as cleft palate.
Sticky-sugary food items such as dried fruit or stickystarchy products such as crackers enable decay-causing
bacteria to grow well. Rinsing with water or eating raw
vegetables and fruits helps clear food debris from the
mouth.
The need for fluid is tremendous for a healthy pregnancy.
Options for beverages include water; caffeine-free items such as herb tea;
nutrient-rich, low-fat milk or unsweetened fruit juice. Alcoholic drinks should be
avoided.
Infants
Infants given sufficient breast milk or formula do not need to have fruit
juice, but only water as an additional source of fluid.
Some infant nutritionists and physicians recommend
that fruit juice not be introduced to a child until age
six months and then, to limit the juice to four ounces
a day in a cup. The pediatrician should be consulted
regarding recommendations.
At no time should children be given a bottle with milk or other
sugar-containing liquid for sleep time, nor should they be
allowed to nurse at will through the night. This promotes tooth decay.
28
Encourage foods that are low in sticky sugars or sticky starches, such as soft
cheese, cooked fruit, cooked vegetables and cooked cereals. Be cautious about
the size and texture of food pieces; young children are especially prone to
choking. Honey can be a source of infantile botulism poisoning and should be
avoided through age one year.
Sound “bites” for infants:
• only formula, breast milk or water in the bottle
• no sleeping at the breast or with bottle
• limited juice and no honey
• foods low in sugars and sticky starches such as soft cheese, cooked
vegetables and fruit, cooked cereals
• purees or small soft pieces of food
A wide variety of foods should be offered to youngsters, to help establish good
eating habits at an early age. Additionally, caregivers need to follow nutritious
eating patterns to set a good example.
Toddlers
The good habits started with infants should be
continued with toddlers. As the children now have all
or nearly all of their primary teeth, they will be able to
handle more firm pieces of food. However, risks for
choking are still high, and caregivers should cut round
or firm items such as grapes. Avoid hard items such as
popcorn, nuts, and crusty bread.
The American Academy of
Pediatrics (AAP) recommends
that young children have
snacks no more than four times a day, to limit the
frequency that teeth are exposed to cavity-causing acid
and the risk of obesity.
Childhood obesity is a major health concern. Because the very young cannot eat
a large amount of food at any one time, the foods offered should be rich in
nutrients, but moderate in fat and low in sugars, with the exception of fruits.
Nutritionists also recommend limiting milk intake so that the child has enough
appetite to eat other healthful foods.
29
Better bets for toddlers:
• no more than four snacks daily
• small pieces soft food
• thirsty? Water, not juices
• low-fat cheese, fresh soft fruit,
•
•
cooked vegetables and other
nutrient-rich foods that are
moderate in fats and low in sugars
limited juice and no sodas
sticky sugars and sticky starches,
such as raisins and crackers, at
mealtime
Healthful options include low-fat
cheese, fresh soft fruit and cooked
vegetables. Water is good throughout
the day and preferred to juice. If juice
is offered, it should be a product with
no added sugar; fruit-flavored drinks
are primarily sugar and water.
The AAP further recommends that
children ages one through six years of
age be limited to four to six ounces of
juice daily. Sugary beverages, such as
juice, or sticky sweets, such as raisins,
should be offered at meals to help limit
the time they are left on teeth.
AAP recommendations for juice consumption to limit sugar and calories:
• Introduce juice into the diet of infants after 6 months of age.
• Offer juice to infants only in a cup, not in a bottle. Children should not be
allowed to carry a bottle, cup or box of juice throughout the day.
• Limit intake of fruit juice to 4-6 oz. per day for children 1-6 years old.
• For children 7-18 years old, limit fruit juice to 8-12 oz. per day.
• Encourage children to eat whole fruits to meet recommended daily fruit intake.
• Read food labels to be certain the product is 100% fruit juice; avoid fruit-flavored
drinks which are mostly sweeteners and flavoring.
School-Age Children
As children get older, they continue to need the
nutrients that support normal growth and
development. Healthful options include:
• whole grains,
• lean meats, poultry and seafood,
• unsweetened fruits,
• vegetables and
• low-fat dairy products.
Unless eaten with other
foods that would help
clean the teeth, limit dried
fruit, ready-to-eat cereal,
chips, crackers and other sources of sticky sugars and
starches. School-age children are often in situations
where they can choose their own foods and beverages;
youngsters who have been raised with healthful options
tend to select more nutritious foods.
30
Peer pressure and advertising have great influence on this
age group as seen in the high consumption of sodas and
candy. Often, schools have vending machines that sell
mostly sugary drinks and snacks. Reduce the negative
effects from these messages by establishing limits on the
frequency and amounts of high-sugar items that are eaten.
Encourage youngsters to rinse their mouths with water or eat
crunchy-juicy fruits or vegetables to clear the mouth of food
debris when brushing is not possible.
Teens
Teenagers, already prone to hormonally
stimulated gingivitis and the anxiety of
emerging adulthood, often find themselves at
odds with basic good oral health care.
However, teens place great value on their
appearance and social acceptability. Point out
that the foods that promote healthy teeth and
gums will also maintain healthy skin and hair.
Unfortunately, teens might choose many
foods that are low in fat but high in sugar, in
the interest of weight control.
Healthful options include lean meats, poultry and fresh
produce, and for snacks, unsweetened nuts or popcorn.
Low-fat string cheese and low-fat yogurt provide important
calcium and protein for growing bones and for reducing risks
of osteoporosis. Regular and diet sodas should be limited
because of the phosphoric acid content that can damage
tooth enamel. Many teens indulge in highly caffeinated
coffee drinks and energy beverages, unaware of the drinks’
high sugar content. Drinking water should be encouraged.
Teens are also at high risk for developing eating
disorders. Anorexia nervosa, bulimia nervosa and
compulsive overeating can promote general
malnutrition that will affect the health of oral tissues by
depressing body defenses against illness and
promoting gum disease. Additionally, some anorexic or
bulimic individuals will choose to suck hard candy or
cough drops for “non-fat nourishment” or to mask odors
31
from vomiting. However, the sugar
increases the incidence of tooth
decay. Self-induced vomiting can
promote loss of enamel (enamel
erosion). The weakened enamel is
more prone to decay, breakage and
hypersensitivity.
Teens:
- more prone to gum disease and less
likely to practice good oral health care….
- grow nearly as fast as infants and need
foods rich in protein, calcium, iron and
vitamins but low in sugars and fats, with
the exception of fruits
Adults
All adults, young and old, are role models for the
youngsters in their environment. To encourage
positive oral health habits in the young, adults need to
show their commitment to regular oral hygiene,
tobacco-free living and nutrient-rich diets. Adults of the
household are usually the “gatekeepers” of food and
can make available healthful options while limiting
access to items that promote dental disease.
Older Adults
Foods low in fermentable carbohydrates and rich in nutrients also help reduce
the risks for chronic diseases such as diabetes, heart disease, osteoporosis and
cancer. Healthful choices include items lower in sodium such as fresh fruits and
vegetables (not canned), foods low in saturated fats such as lean poultry, nuts
and seafood; and foods high in calcium such as low-fat milk. These same
choices can help manage chronic diseases to maintain a good quality of life.
Other Factors Affecting Oral Health
Daily oral care and food choices play a significant role in oral and total health.
However, there are other factors that affect oral health, including tobacco,
alcohol, drugs, herbal remedies and oral embellishment.
Tobacco
Tobacco products, both smoked and smokeless,
increase the risk of oral cancer, periodontal
disease and dental caries. Smoked tobacco
products include cigarettes, cigars and pipes.
Smokeless tobacco products (“spit” tobacco,
“chew” or snuff) are chewed, sucked on or applied
directly between the cheek and gum.
32
They are NOT safe alternatives to smoking tobacco. In addition to the toxic
components of tobacco, smokeless tobacco has added sugars.
Oral complications:
• Exposure to heat (smoked tobacco) and toxins
• Tissue trauma and lacerations
• Stained teeth and tongue
• Halitosis (bad breath)
• Tooth sensitivity
• Gum recession
• Root caries (decay on roots of teeth that have
recessed gums)
• Dental caries (smokeless tobacco products add sugar and flavoring)
• Periodontal disease
• Oral cancer – approximately 80-90% of all oral cancer is attributed to
tobacco product use
A 2003 report in the Journal of the American Medical Association shows
evidence that passive (indirect) or “second hand”
smoking can also influence oral health. A large
national health and nutrition study linked
environmental tobacco smoke and the risk of
cavities among children. Blood levels of a chemical
marker for tobacco smoke were higher among
children who had more decayed and filled tooth
surfaces in their primary teeth.
Alcohol
Excessive alcohol use increases the risk of oral
cancer, causes xerostomia (dry mouth) and
might lead to behavioral changes that adversely
affect oral health. When used in combination
with tobacco products, excessive alcohol use
dramatically increases the risk of oral cancer.
Xerostomia often occurs with alcohol consumption. Since
saliva acts as an oral lubricant, cleanser and acid neutralizer, reduced salivary
flow leads to increased risks for tooth
Xerostomia
decay and periodontal disease.
(zir-oh-STOH-mee-ah):
Dryness of the mouth due to a
Excessive alcohol use can cause
lack of saliva. Xerostomia can be
behavioral changes that further
contribute to oral disease. Unhealthy
caused by alcohol intake,
dietary habits, such as eating
diabetes, medications such as
infrequently or substituting alcohol for
antihistamines and cough syrups,
meals, can cause nutrition imbalances.
cancer radiation treatment to
the head/neck, or surgical
removal of salivary glands.
33
Poor nutrition negatively impacts the body’s immune
system and increases the risk for periodontal disease.
Personal hygiene practices are often changed through
alcohol overuse/abuse. Regular tooth brushing and
flossing, are often neglected if not completely forgotten.
This neglect can lead to both cavities and periodontal
disease.
Excess alcohol
increases risks
for:
• xerostomia
• cancer
• tooth decay
• gum disease
• malnutrition
• poor oral
health care
Tobacco and Alcohol Use: Oral Cancer Links
Lifestyle choices, that include tobacco use and
excessive alcohol consumption, greatly increase the
risk for cancers of the lips, mouth, tongue, gums and throat.
With rates of oral cancer increasing, it is important to be aware
of signs and symptoms.
Possible oral cancer indications that should be evaluated by a dental
professional:
•
•
•
•
•
Irritation such as tenderness and burning, or a sore
that won’t heal, in or around the mouth, and that
persists longer than two weeks
• Pain or numbness anywhere in the mouth or on the
lips
• A lump in or about the mouth, face or neck
• A thickened, leathery, wrinkled or bumpy patch inside
the mouth
• Color changes in oral soft tissue (normally a healthy
pink) to red, white or gray spots or patches
Difficulty chewing, swallowing, speaking or moving the jaw or tongue
A change in the way teeth fit together
Ear pain
Persistent hoarseness
Oral cancer screenings should be performed by a dental professional at least
annually. Individuals should become familiar with what is “normal” in their mouths
and do a monthly oral self-exam. Changes must be evaluated by a dental
professional. With early detection and treatment, death rates from
oral cancer are greatly reduced.
Prescription/Over-the-Counter Drugs
Many prescription and over-the-counter (OTC) drugs are in the form
of liquids and chewable tablets. Manufacturers might add sugar to
improve the flavor and patients’ willingness to take the medication.
When taking multiple daily doses, the mouth and teeth are
continuously exposed to the added sugars.
34
Prescription and OTC drugs can also increase the possibility
of xerostomia (dry mouth), which, in turn, increases the risk
of tooth decay and periodontal disease. Bacteria flourish
when less saliva is present to clean teeth and neutralize the
germs’ acidic wastes. Xerostomia can also cause poor dietary
intake as well as speech dysfunction. Nutritional deficiencies
can occur as chewing healthful foods becomes painful, and
swallowing becomes difficult. Sucking hard candies/lozenges
might seem to help with speech
and/or swallowing, but sugar products
increase the risk of tooth decay.
Many medications that have the prefix “anti-” (i.e.,
antidepressants, antihistamines) can cause xerostomia.
Individuals should check with their own physicians and
pharmacists for possible drug side effects.
Over-the-counter products are available to help reduce
the effects of dry mouth. These include:
• Saliva-substitute gel
• Toothpaste
• Chewing gum
• Mouth rinse
Check with a dental professional for specific product
recommendation and information.
Recreational or “Street” Drugs
Clinical research reports are now emerging,
linking classes of illicit drugs to oral signs
and symptoms. Drug abusers have a higher
incidence of tooth decay, missing teeth and
periodontal disease, possibly resulting from
neglect more than the drugs themselves.
Stimulants, such as cocaine and methamphetamines, can cause:
 xerostomia,
 halitosis (bad breath),
 bruxism (teeth grinding/clenching),
 gingival (gum) tissue laceration and
 infection from drugs directly applied to tissue.
35
Because stimulants produce a loss of appetite, nutrient deficiencies often follow.
Poor nutrition can result in:
 angular cheilitis (cracked corners of lips),
 necrotizing gingivitis,
 oral candida infections (thrush) and
 glossodynia (pain or burning tongue).
Although the exact cause has not been
determined, people who use opiate drugs, such as
heroin, might exhibit large areas of tooth decay,
especially at the gingival margins (gumline).
Compared to non-users, marijuana users have higher rates of dental caries,
missing teeth and more bacterial plaque and tooth staining. It is not certain why
this sedative has these pronounced effects.
Herbal Remedies
Herbal remedies are plant-derived, “medicinal” products
that are classified as dietary supplements. Unlike
traditional medications in the United States, the Food
and Drug Administration (FDA) does not require testing
for herbal supplements before they are sold. These
supplements can interfere with prescription drugs.
Individuals should inform their medical and dental team
of all remedies being taken, including herbs/herbals.
Some oral side effects of herbal remedies can include:
 Xerostomia (dry mouth),
 Increased saliva flow,
 Aphthous ulcers (canker sores),
 Lip and tongue irritation and swelling,
 Gingival (gum) tissue bleeding,
 Tongue numbness and
 Oral and lingual dyskinesia (impaired movement of mouth and tongue).
Oral Embellishment
Oral embellishment includes piercing, tattoos, and various
dental jewelry. Embellishment can increase the risk of
infection, tooth damage, speech problems, nerve damage
and periodontal destruction.
36
Oral piercing can cause a variety of oral and overall health complications. These
include, but are not limited to:
 fractured or broken teeth
 keloid scars
 nerve damage
 altered speech
 permanent numbness
 damaged sense of taste
 gum recession
 toxic shock
 increased saliva flow
 enlarged lips and/or tongue
 permanent drooling
 life-threatening stroke
 risk of diseases spread
 allergic reactions to metals
through unsanitary needles
 swallowing or inhaling jewelry
Oral tattoos can put the recipient at risk for infection from diseases that pass
through blood or body fluids. Infection can occur if the tattoo is not placed under
sanitary conditions with standard infection control procedures, including sterilized
instruments, gloved technicians and sterile, disposable needles.
Dental jewelry or “tooth fronts” are removable, decorative items to be worn over
the teeth. They are usually custom-made. Many contain gold or platinum and are
embellished with diamonds or other precious gemstones. They must be removed
prior to eating. Dental jewelry, while worn, can cause:
• speech problems (slurring or lisping),
• gum tissue irritation,
• tooth chipping and
• tooth cracks or fractures.
Some dental jewelry is permanent and might include
a jewel-imbedded gold crown, symbol, initial or other design that is fused to the
tooth enamel. They are often made and placed by a dental professional. Most
require removal of tooth structure, which weakens the tooth.
Cultural Competence and Oral Health Education
In this increasingly ethnically diverse society, health educators need to
understand and acknowledge the varying cultural backgrounds of their audiences
and colleagues. When patients and clients feel their beliefs have been taken into
consideration, the educators will be better able to impart health messages that
are acceptable, relevant and appropriate for their audiences.
37
Persons of color generally experience higher rates of illnesses, such as dental
disease and high blood pressure, than their white counterparts. At the same time,
these ethnically diverse groups, especially if they are from low-income
households, often have less access to adequate health care.
In this discussion, “culture” refers to the total lifestyle of
people from a particular social group, including their shared:
 ideas,
 symbols,
 preferences and
 material objects.
Culture includes the group’s beliefs and practices about the
supernatural and religion, diet and health, parenting and
views about how people are related to each other and to the
larger universe.
All people, not just new immigrants to the U.S., carry with them their beliefs and
expectations about health, disease and the healing process. These can present
special challenges to the health educator. Attention to details such as tone of
voice, eye contact and personal space, not just language or dress, can facilitate
communication with the group. Crucial, too, is understanding how one’s own
cultural values affects the process of teaching others.
Even though by definition, culture is shared by members of a particular group,
individuals will vary in how much they abide by the rules or “norms” of their
culture. Adoption or acceptance of a new culture moves along at varying speeds
and to different degrees.
There are cultural core values and beliefs that appear in a group, but even within
a group there will be variations. For example, in many cultures children are
expected to passively obey their parents, although parents will vary in the
strength of this belief and will act upon it in dissimilar ways. Some cultures are
male-dominated, yet there can be found women in those groups that will take
power in some decision-making. However, several values, such as those
promoting strong family bonds, are common to many cultures.
To make a difference in teaching families, social worker and author J. Fialka, in
the publication It Matters: lessons learned from my son, suggests:
• anticipate and accept families’ feelings.
• be compassionate and respectful of families.
• bridge support between families and the larger community by becoming a
model.
• provide assistance, knowledge, and resources to families about their
children’s special needs.
38
•
•
acknowledge and celebrate the
big and small milestones and
accomplishments of the families.
know when to back off.
The effective health educator learns
about cultural values of the audience
before working with them. Members of
an unfamiliar cultural group can be a
good resource to start and guide the
health educator’s efforts. Questions to ask group members should include
inquiries about major beliefs, attitudes, values, roles of women versus men or
elderly versus young, and other views held by the group.
Possible Questions/Helpful Information:
Food practices – the foods, flavors and meal patterns that are acceptable and
unacceptable in the culture.
 What are typical foods in the diet?
 How frequently used are highly acidic foods such as lemon, vinegar or
sour fruits which can impact the strength of tooth enamel?
 What are common sources of sugars and starch?
 Are certain items considered “healing” foods and others, diseasecausing?
Oral health behaviors – the practices and attitudes regarding care of the mouth,
teeth, gums and tongue.
 What cleaning techniques and tools are used?
 How often are teeth and gums cleaned?
 What oral hygiene routines are followed by young/old, new
immigrants/those who have been in the U.S. for longer periods of
time?
Parenting philosophy – the attitudes and beliefs about how the young should
be taught the practices of the culture.
 Who has the primary job of child-rearing in the family?
 How much influence do extended family members have in childraising?
 What is the typical age that children are weaned from bottlefeeding/nursing?
 How much decision-making is given to children regarding foods
purchased for the household?
 How much independence do children have in selecting their own
foods?
 Is food commonly used to pacify children?
 Are sweets given to reward children?
39
Religious beliefs – the role religion plays in the group’s view of healing and
health.
 Is divine intervention the only way that one can recover from infection
or illness?
 Is fasting a part of worship?
 How will abstinence from food and drink impact oral treatment and
care routines?
 Are certain days considered holy and no dental visits should be
scheduled?
Health literacy – group members’ access to and use of medical/dental care
services; their ability to read, understand and act upon health information such as
insurance forms, informed consent papers and medical/dental advice.
 What are the challenges for individuals to get and use dental and
medical care?
 Where do they get help with access to or information about health care
services?
Health beliefs – the group’s views on health and the causes of disease.
 How important is oral health?
 What is the role of prevention in oral health?
 How do people get dental disease?
 How do they get better?
 What are the attitudes and beliefs about medical and dental visits?
Culture and Health Perceptions
In the data-based “biomedical” model of health and illness that
underlies traditional Westernized medicine, disease is usually
caused by microorganisms such as bacteria or viruses; patients
are to be proactive and act in their own self-interests; health is a
combination of one’s lifestyle habits, environment and inherited
traits; and treatment is based on scientific evidence.
However, for much of the world and many in the U.S., health
results from “balance” or harmony with natural internal and
environmental forces including “hot” and “cold” humours or
energy, other persons’ positive or negative regard (curses or the
“evil eye”), a greater spiritual being or, simply, fate. Good
spiritual, mental and physical health interweave to achieve
overall well-being. Imbalance in any one or more results in illness.
Non-Westernized, native cultures follow more the traditional or “folk healing”
methods. An extension of these beliefs is a fatalism, or the acceptance that
whatever happens is unavoidable and should simply be endured. These two
views can conflict in the dental office and in health education.
40
Many with a traditional orientation see no reason to prevent
illness, including dental decay and periodontal disease, as it
is their fate to suffer these diseases. Groups might view
preventive care as a luxury, not a necessity, or that getting
sick is predestined and cannot be changed. In terms of
dental care, many obtain only restorative care or extractions,
and do not change behavior to avoid oral disease.
These beliefs greatly influence help-seeking behaviors and
attitudes toward health care providers. Culturally based
views of illness, its causes and the healing process may lead to clients not using
information, not seeking medical/dental help and not following treatment from
traditional Western-based practitioners. For example, some individuals in the
U.S. fear they will contract AIDS from needles used to administer medicines or
anesthetics. Some groups view U.S. drinking water as “unsafe” and will not drink
it, losing an easy opportunity to obtain fluoride.
To be “culturally competent,” service should reflect the attitude that cultures
might differ from each other, yet all cultures are equally valuable and important.
Culturally competent services promote acceptance and participation among the
groups who receive it because the interactions reflect respect for individuals,
their personal preferences and cultural differences.
It is not possible for health educators to know and understand every detail about
every culture. However, they can maximize their effectiveness when working with
people whose culture is unfamiliar to them. Whether the groups are immigrant
ethnic minorities, teens, persons in drug recovery, pregnant women, mature
adults or preschool parents, educators should learn about the attitudes, beliefs
and practices of the individuals with whom they are working (teaching). The
audience’s viewpoint will be the starting point of how the educator can influence
that person’s health behaviors.
The following information has been collected from a variety of references,
including a limited number of focus groups. This information is not meant to
stereotype groups, nor is it meant to be an all-inclusive list of groups, but
only to give a general starting place for working with some populations.
Depending on factors such as the time spent in the U.S., education achieved,
generation, age and group-peer pressure, an individual might be more or less
accepting of American culture compared to the native culture. If not enough
accurate information is available for study about specific cultural groups, you
might wish to consult with others who know the culture or to organize focus
groups to gather information from representative group members themselves.
41
Asian, Pan-Asian, Pacific Islander
Many of these groups believe in late weaning, about two years of age, unless the
mother is already pregnant with another child. Iron deficiency anemia is a
common result from extended use of the baby bottle, especially among
Southeast Asian toddlers. Studies have shown those of Asian heritage
experience more dental disease than Hispanics, Caucasians, and blacks. Asians
also had more periodontal needs than all other groups.
Chinese
Regardless of age and gender, traditional Chinese
persons believe they are susceptible to dental
disease. They expect to lose teeth in old age and that
nothing can be done to prevent it, although tooth loss
is considered undesirable in all except elderly people.
In fact, elderly persons believe that having teeth in old
age will “eat away their children’s fortune,” bringing
bad luck to the family. The presence of teeth in a
newborn is also seen as bad luck, a sign of
retribution.
Did you know…
…the modern
toothbrush is a
Chinese
invention from
about a
thousand years
ago, with
bristles made
from a horse’s
mane attached
to handles of
ivory…?
The role of sugar in the production of dental disease
is not generally recognized, although “hot energy” or
“hot humour” and “toothworms” are considered to be
contributors. Plaque on the tongue might also be
interpreted as a sign of disease in another part of the
body. Halitosis can be attributed to “hot humour” and not necessarily
related to plaque. Periodontal disease is prevalent among native Chinese.
Deeply ingrained is the fear of blood loss, a cultural concept involving
“weakening of the body.” The timing of dental treatment is important, and
dental extractions, in particular. Blood pressure is believed to rise at night,
and so, blood has more “force” that would promote bleeding.
Consequently, traditionalists worry that extractions that take place in the
late evening can result in non-stop bleeding.
Elderly Chinese persons find it embarrassing to keep returning to the
dental office for follow-up treatments for dentures and partial dentures.
They are afraid of troubling the dentist and becoming an “unpopular”
patient. In their native China, appointment systems are not always used,
and dentist or doctor “shopping” is prevalent. For many adults, the choice
of dentist depends on recommendations from friends and family. Western
dentistry as a whole can be seen as inadequate because it is so different
than in their homeland.
42
The use of toothpicks is prevalent among native Chinese, although this is
primarily intended to indicate or express their appreciation of the meal.
Flossing and the use of mouth rinses are uncommon, particularly among
the elderly.
Toothache, abscesses and swelling are the most
common dental conditions for which traditional
remedies are used. In general, dependence on
these treatments increases as age increases and
among females. Herbal tea, Tiger Balm, salt
water, toothache solution, Japanese medical
plaster, rum, kerosene, White Flower Oil, Melon
Cream and other available Chinese medicines are all used for dental
problems.
Hmong
Originally from the mountainous regions of Laos, the Hmong place great
importance on a proper name, and calling a person by the wrong name is
to commit a significant blunder. The Hmong believe a person has three
souls, the third of which must be called by a special naming ceremony on
the third day after birth. The third soul will not enter the child who receives
the wrong name, causing the child illness or even death.
East African
Traditional Somalis use a root-based chew stick called “Muswaki” or branches
collected from the Roomay tree to clean teeth, much like Middle Eastern peoples
use chew sticks. The sticks are about six to eight inches long and can be can be
purchased at Somali grocery stores in the U.S. Sticks are first soaked in water for
a day, used for about a week and then replaced if the users can afford the cost.
Such sticks are used successfully for generations in many other parts of the
world; they are similar to manual toothbrushes.
Tooth extractions among native Somalis are commonly performed at hair cutting
parlors. To prevent diarrhea in children, Somali tradition calls for the extraction of
primary cuspids while Ethiopian beliefs dictate the removal of lower incisors.
Some traditional Somali breast-fed infants are supplemented with goat’s milk at
age six months; nomadic Somali mothers feed their child cow’s milk mixed with
water at three months. Urban Somalis feed infants soft foods, such as bananas
and rice at eight months. Traditionally, Somali families are large, and by age
three years, a child is responsible for his/her own oral cleanings.
Latino
Good parenting means that children, especially boys, consume all the food
served them at meals; thinness in a son would indicate parental neglect. Some
children vomit because of the excess food and consequently, suffer oral effects
43
from the acidic stomach contents. Traditional favorite flavors for children and
adults include lemon and other tart items, with tooth erosion as a consequence.
Pregnancy is seen as a natural part of life, and not a medical condition that
requires timely medical and dental care during the prenatal months. Many
expectant mothers report craving and frequently eating lemon, tamarind and
other acidic fruits.
The traditional practice of “caliente/frio” (“hot/cold”) dictates that upon childbirth,
the mother and child are kept out of public for at least a month. This can affect
post-pregnancy medical/dental visits. “Caliente/frio” also prescribes certain foods
for mother to eat after delivery, in order to “rebalance” her body energy. Nursing
is common, but so is use of baby bottles beyond a child’s first year. Common in
the bottle are juices and traditional sweetened beverages such as “rice water” or
horchata. Primary teeth are called “milk teeth.” Since these first teeth are lost,
many traditional Latino families do not consider early preventive care such as
regular toothbrushing to be a priority.
Latino children are less likely than Anglo children to use seat belts or to be
placed in child safety seats. Alcohol appears to be the major drug of abuse in this
ethnic group.
Middle Eastern
Families are patriarchal, with the father viewed as the
strong and important head of the household. Typically,
persons are modest and value privacy. Speaking loudly
signifies an important issue; repetition of phrases also
stresses importance. Personal space is approximately two
feet which is often misinterpreted as “being demanding.”
Generally, mothers nurse their infants and rely less on
bottle feeding.
In the Afghan
language,
“decay” is
translated as
“toothworms,”
for “the worm
will eat your
teeth…”
Arab
Diet is one factor in health. Foods are classified as “hot” or “cold” and
need to be balanced in eating and drinking. Many elderly believe illness is
caused by evil, bad luck, distress and/or imbalance. A heavier person is
considered to be healthier than a thin person. Preventive care is lacking
because talking about illness will cause it to happen; many seek care only
when symptoms arise. Religion is generally a part of their identity, and
many are Muslim, who fast during the month-long Ramadan observances.
Egyptian
As in many other cultures, food is an important part of the social system.
Traditional meal patterns are high in bread and protein. Unfortunately,
foods can be high in fat, sodium and sugar. Other high-risk behaviors
include lack of exercise and smoking tobacco. Native Egyptians are often
44
victims of the “modern” diseases of obesity, hypertension and other
cardiovascular disease and type II diabetes.
Iranian
Health problems of immigrant Iranians such as hepatitis A and B,
tuberculosis, protein inadequacy and vitamin deficiency are related to
underdevelopment of their native country. Canned, frozen and fast foods
are thought to have less nutrients than fresh products. Fresh fruit and
leafy green vegetables are important in the diet. As in many other cultures,
herbal remedies are used.
Muslim
Followers of the Islam religion are called “Muslim” and can be of any nationality
or race. Dietary code dictates eating to care for one’s body and avoidance of
pork, alcohol and caffeine. One of the most important times in the Islamic year is
Ramadan, a month-long religious observance when Muslims are asked to fast,
going without food and water from dawn until dusk. Fasting, one of the Five
Pillars of Islam, is a basic and essential ritual for all practicing Muslims as a
means of understanding sacrifice and the non-material. Fasting also allows the
individual to appreciate hunger in those who have no food.
Dental treatment for a Muslim patient during Ramadan can be affected because
routine procedures might unintentionally cause a break in the fast, for example, if
the patient accidentally swallows water during the dental exam. Patients might
also hesitate to use any mouth rinse, fearing absorption of the liquid through
mouth tissues or accidental swallowing.
Reasonable modifications can be made to respect religious practices while
working with the patient. Including:
 recommending or prescribing alcohol-free mouth rinses
 providing treatment outside the hours of fasting
 changing timing and/or routes of medication
A main purpose of fasting in general, and especially during Ramadan, is to teach
followers discipline and self-restraint. These qualities can be helpful to initiate
and cultivate positive oral health behaviors. The month of Ramadan might not be
a practical time to start direct health promotion activities.
However, reinforcing the positive spiritual and character-building benefits of
fasting could be a helpful motive for change.
For example, smoking is not acceptable during the hours of the fast. This can be
a valuable opportunity to encourage a reduction or stopping of tobacco use.
Dietary patterns can be another area where the change of routine behavior
during Ramadan can help gain long-term health benefits. During the fast,
individuals exert great self-discipline and motivation to refuse food or water for
the prescribed hours. After the month of fasting, the individual can be
45
encouraged to maintain such discipline by, for example, reducing intakes of
refined carbohydrates or tart foods, cultural favorites that are detrimental to teeth.
Native Americans
Some individuals still practice tribal healing ceremonies. Tribal practices are
often considered sacred; carefully consider questioning the practices to preserve
client trust. Initial eye contact is important but a prolonged look is considered
disrespectful. Great respect is given to the elderly.
Certain tribes classify foods as “strong” and “weak.” For example, milk is viewed
by the Navajo as “weak,” and not considered healthful; many are lactoseintolerant. Some individuals consult traditional healers to diagnose their
condition, then see an Indian Health Service physician for medicine to cure it.
Public health concerns for Native Americans include high rates of alcoholism,
Type II diabetes mellitus, tuberculosis and cardiovascular disease, all of which
affect oral health status.
Pakistani and Indian
Many native mothers extend the use of baby bottles beyond the first year, until at
least age 15 months. Adding sweet or solid foods to the bottle, such as sugar,
honey, chocolate powder or biscuits tends to be common, starting at around age
9 months. Many youngsters routinely practice “pica,” eating items typically
viewed as inedible, such as clay. The clay can bind with calcium and other
minerals, leading to a lack of the nutrients that can affect bones, teeth and blood.
To clean teeth, many natives rely on chew sticks, short pieces of plant roots or
branches used much like toothbrushes. Common among this group are chewing
on beetle nuts and “reverse smoking,” where the lit portion of a cigarette is held
in the mouth as the smoker inhales. Both practices carry great risks for oral
cancer.
Summary of Cultural Competence and Oral Health Education
Public dental health education addresses the oral health of groups in the
communities in which we live. However, changes in health behaviors come one
person at a time. Establishing rapport improves the health educator’s credibility
early on in the teaching relationship and helps drive the change process.
“Coaching” the individual/family toward better oral health practices is not always
easy. At the 2003 Iowa State University Cultural Perspectives on Parenting
conference, for effective cross-cultural work with families, W. Allen, PhD,
suggested that the educator:
•
•
•
•
start by understanding how your own cultural values affect your work;
always balance cultural differences and similarities;
realize there is at least as much diversity within groups as between
groups;
recognize and appreciate different family and cultural “worldviews;”
46
•
•
cultivate an attitude of openness by being respectful, being collaborative,
managing each party’s anxiety about not being understood and being
open to your clients so that you never stop learning.
47
References
Allen, PhD, W. (2003, October). Cultural Perspectives on Parenting. Presented at
the Iowa State University - University Extension conference, Cultural
Perspectives on Parenting, Ames, IA.
National Cancer Institute. (2003). Smokeless tobacco and cancer: questions and
answers. Retrieved August 21, 2003 from
http://cis.nci.nih.gov/fact/3_63.htm
Aligne, C.A., Moss, M.E., Auinger, P., & Weitzman, M. (2003). Association of
pediatric dental caries with passive smoking. Journal of the American
Medical Association, 289, 1258-64.
ADA Division of Communications, American Dental Association. (2001).
Preventing periodontal disease. Journal of the American Dental
Association, 132, p.1339.
Boardman, R., & Smith, R.A. (1997). Dental implications of oral piercing. Journal
of the California Dental Association, 25, 200-207.
Dasgupta, A. (2003). Review of abnormal laboratory test results and toxic effects
due to use of herbal medicines. American Journal of Clinical Pathology,
120, 127-137. Retrieved August 5, 2003, from WebMD Medscape Web
site: http://www.medscape.com/viewarticle/458306
Eshiett, M.U-A., & Parry, E.H.O. (2003). Migrants and health: a cultural dilemma.
Clinical Medicine, 3, 229-231.
Fialka, J. (1997). It matters: lessons from my son. Huntington Woods, MI: J.
Fialka.
Freda, M.C. (2004). Issues in Patient Education. J Midwifery Womens Health, 49,
203-209. Retrieved June 7, 2004, from WebMD Medscape Web site:
http://www.medscape.com/viewarticle/478283
Jordan, J.A., & Stein, T.J. (2002). To pierce or not to pierce? Access, 16 (8),
56-58.
Myers, P.J. (n.d.). Drug Abuse. Retrieved July 10, 2003, from University of
Texas Medical Branch Correctional Managed Care Web site:
http://www.utmb.edu/cmc/drugabuse.htm
Stiefel, A.J., Frandsen, L.C., Yamagata, P.B., & Horike, J.Y. (1998). Oral care for
persons with disabilities, units a-f (2nd ed.). Seattle: Dental Education in
Care of Persons with Disabilities (DECOD),University of Washington
48
School of Dentistry.
Salimbene, S. (2000). What language does your patient hurt in? a practical guide
to culturally competent patient care. Amherst, MA: Diversity Resources.
Salimbene, S., & Graczykowski, J.W. (1995). 10 tips for improving the
caregiver/patient relationship across cultures. In S. Salimbene & J.W.
Braczykowski, When two cultures meet: American medicine and the
cultures of diverse patient populations, book 1, what language does your
patient hurt in? An 8-part series of practical guides to the care and
treatment of patients from other cultures. Amherst, MA: Inter-Face
International, Amherst Educational Publishing.
Scott, B. (2001). Mouth art. Access, 15 (8), 18-24.
Wilkins, E.M. (1999). Clinical practice of the dental hygienist (8th ed.).
Philadelphia: Lippincott Williams and Wilkins.
Worku, A. (2003). An overview of herbal supplement utilization with particular
emphasis on possible interactions with dental drugs and oral
manifestations. Journal of Dental Hygiene, 77, 37-46.
What is Gum Disease? (n.d.). Retrieved September 18, 2003, from
http://www.agd.org/consumer/topics/perio/main.html
General Resources
The American Dental Association – www.ada.org
The American Dental Hygienists’ Association – www.adha.org
The Association of Professional Piercers - www.safepiercing.org
49

A Healthy Mouth for a Lifetime: Beyond the Basics

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