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 Dental Health Educator, Dental Health Initiative of San Diego/Share the Care Nancy Starr, RDH, MPH Dental Health Educator, Dental Health Initiative of San Diego/Share the Care 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.

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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………………………………………………………………….

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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……………………………………………………………………

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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

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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.

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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

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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. ©2004 DHI/Share the Care

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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.

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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.

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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.

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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

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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.

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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.

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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

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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,

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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. ©2004 DHI/Share the Care

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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.

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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.

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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

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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.

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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. ©2004 DHI/Share the Care 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.

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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.

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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.

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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.

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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.

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•

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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?

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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.

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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.

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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.

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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

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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

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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

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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;”

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• •

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.

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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

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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

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