Oral Hygiene education guide for the Nepalese people

Author: I.M. Omlo

Second edition: September 2009

I have written this oral hygiene guide for the Nepalese people for the foundation Netherlands Oral Health Society (NOHS). The first edition was published in February 2009. After the Dental Camp in March 2009 I adjusted this guide with a few changes. The result after those adjustments is this second edition.

The experiences from dentists and dental hygienists, who took part in the Dental Camps of the NOHS, have lead me to write this guide.

A clear and unequivocal guide about what the training and education should be like didn’t exist. This applies particularly to the location Chitwan. This guide can be seen as a first step.

I would like to thank a number of people who have helped me with this guide. First of all I would like to thank Gerjen Winkeler and Angela Bugel. They are both board members and editorial staff members of the NOHS. We have ex-changed a lot of ideas what the guide should look like. They also gave me a lot of useful tips. Secondly dental hygienist Léonie Dumoulin who also played an important role, I appreciate her input.Thirdly I would like to thank my colleagues of the Center for Dentistry and Oral Hygiene, Hanze University Applied Sciences Groningen, Department of Oral Health Care (The Netherlands) Marguerite Rothwell and Roelf Sikkens for their reviewing the English and suggested corrections. Finally I would like to thank the foundation United Mission to Nepal (UMN) for making this guide possible. I have gained much a lot of inspiration from its instruction book ‘Oral Health’ and its manual for Health Workers ‘Oral Health Orientation Programme’.

Suggestions and/or additions concerning this guide are very welcome. Please contact: ingrid_omlo@hotmail.com

Ingrid OmloGroningen

Preface

Chapter 1. Introduction 4

Chapter 2. The subjects of oral health promotion activities 6

2.1 Functions of the mouth en teeth 62.2 Oral anatomy 62.3 Dental anatomy 72.4 The replacing of the primary teeth by the permanent teeth 92.5 Breast-feeding and bottle-feeding 92.6 Food/nutrition and dental decay 92.7 Gum diseases 102.8 Oral cancer 112.9 Tooth brushing including (instruction with pictures) 2.9.1 Points for attention 11 2.9.2 A demonstration of the bass method with the brush model for adults 12 2.9.3 A demonstration of the horizontal scrub method with the brush model for children 16 2.9.4 Use of a datiwan 18

Chapter 3. Materials and key points to remember when giving oral hygiene information and instruction at primary schools 19

Appendix I. Table of activities 20

Appendix II. Information sheet of brushing 22

Colophon 24

Contents

4

Chapter 1. Introduction

This guide serves as background information, which can be used along with the instruction book ‘Oral Health’ of the foundation United Mission to Nepal (UMN) which is based in the capital of Nepal Kathmandu. See figure 1 for a picture of the instruction book.

The guide is meant for volunteers who will be giving information on oral hygiene and education to the local Nepalese population in the areas of the Dental Camps of the foundation Netherlands Oral Health Society (NOHS).

Volunteers are:- dentists, dental hygienists and assistants who participate in the Dental Camps

of the NOHS; - Nepalese teachers in primary education who can understand and speak English; - Nepalese people who help in the Dental Camps who can understand and speak

English.

The aim of oral hygiene education and information sessions is to inform the Nepalese people of the benefits of good oral hygiene by using local materials.In addition, these sessions aim to improve the oral health of the Nepalese adults and children. This guide explores and explains the topics which are used in oral hygiene instruction. The materials needed when giving oral hygiene instructions are also described in this guide.

Furthermore, an overview of activities that can be used to deliver the message of good oral hygiene can be found in the appendix.

This overview is intended for the participants of the Dental Camps of the NOHS who want to participate in the oral hygiene instruction and information sessions.

5

Figure 1 Instructionbook ‘Oral Health’ of UMN

6

Chapter 2. The subjects of oral health promotion activities

2.1 Functions of the mouth and teeth

- talking- smiling- to look good and bad - singing- biting and chewing

2.2 Oral anatomy

- What’s in your mouth?

www.nytimes.com

7

2.3 Dental anatomy

- Which different types of teeth can be found in the adult mouth?

Incisors: These are the eight front teeth: four upper teeth and four lower teeth. Their functions are to cut and bite off food.

Canines: These are four pointed teeth at the corners of the mouth: two up-per canines and two lower canines, one on each side.

Premolars: There are eight of these teeth in the adult mouth: four in the up-per jaw and four in the lower jaw, two on either side. They are situated just next to the canines. They are used to tear and partly grind food.

Molars: There are twelve in total, six in the upper jaw and six in the lower jaw, three on each side. The molars are termed as ‘first molar’, ‘second molar’, and ‘third molar’. This is based on their order of eruption. The third molar is also called the ‘wisdom tooth’. The function of the molars is to grind food.

bpkihsdentistry.tripod.com

8

- What are the parts of a tooth?

A tooth consists of a crown and a root. The crown is seen in the mouth. The gums and bone cover the root.

Enamel is the outer covering of the teeth and is the hardest substance in the body

Dentin is a layer under the enamel. It is less hard than the enamel. It forms the bulk of the teeth

The Pulp contains nerve and blood supply to the teeth The Cementum is hard and covers the root.

The teeth are held in place by: Bone Fibres which join the root of the teeth to the bone Gums

http://www.scientificpsychic.com/health/teeth.html

9

2.4 Replacing of the primary teeth by the permanent teeth

The baby teeth start erupting at the age of approximately 6 months. By the age of three years all the baby teeth will have erupted. The baby teeth are replaced by the adult teeth between the ages of six and thirteen years. The baby teeth become loose and fall out. This is because of the slowly dissolving of the roots of the baby teeth by the pressure of the permanent teeth erupting under the baby teeth. This is a natural process of human development.

2.5 Breast-feeding and bottle-feeding

Breast-feeding is more nutritious for the body than bottle-feeding. In addition, breast-feeding provides immunity to fight diseases. Bottle-feeding doesn’t provide the immunity required to fight diseases. Bottle-feeding is also dangerous for the teeth as it may contain a lot of sugar. Frequent bottle-feeding increases the risk of tooth decay. Breast-feeding contains less sugar, so this is good for the teeth.

Look in the instruction book ‘Oral Health’ page 7 and 15 for pictures.

2.6 Food/nutrition and dental decay

Foods and drinks with sugar, such as sugar cane, biscuits, chocolates, ice cream, sweets and cola, are unhealthy. When you eat sugary foods or drink sodas frequently throughout the day, the enamel that protects your teeth is constantly exposed to acids.

vdc.dentistindia.com

10

Sugary or starchy foods eaten with a meal are less harmful to your teeth than when they’re eaten separately, possibly because the production of saliva, which washes away the sugar and bacteria, is increased. Eating sugary foods before you go to bed can be the most damaging (especially if you don’t brush your teeth afterwards) because you don’t produce as much saliva when you sleep.

For most people, it’s hard to cut out sweets completely, so try to follow these more realistic guidelines: Eat carbohydrates (sugars and starches) with a meal. If you can’t brush your teeth after eating, rinse your mouth with water. Don’t eat sugary foods between meals. If you snack, eat non-sugary/healthy foods, such as cheese, raw veggies,

green vegetables, eggs and apples

Eating sugar is a major cause of tooth decay. If the food is not removed with a datiwan or toothbrush, bacteria in the mouth eat the food to produce acid. Over time the acid dissolves our teeth and causes a hole. This is called “tooth decay”. Eating sugar-rich foods causes more teeth decay, because bacteria like sugar. The more sugar-rich food you eat, the greater the holes in the teeth develop. When the holes grow large they reach the tooth nerve, which then starts to ache. This can cause swelling in your mouth and face.

Look in the instruction book “Oral Health” page 9, 17 and 19 for pictures.

2.7 Gum diseases

- What supports the teeth? A tooth is like a tree. Both need strong foundations. Trees need earth and

teeth need bones and gums to support them.

Look in the instruction book ‘Oral Health’ page 21 for a picture.

- Why do gums bleed? When bacteria are not removed from the gums with a toothbrush or datiwan,

the gums can become inflamed. Then the gums are swollen, red and bleed easily. This is unhealthy!!

11

- Why do teeth become loose? Bacteria left around the necks of the teeth will get hard if they are not

removed. They contain more bacteria and this will lead to destruction of the supporting bone. If a tree has no earth to support its roots it will fall over. In the same way if the bone and gums around the root of a tooth are destroyed, the tooth will become loose. Eventually the tooth will fall out.

Look in the instruction book ‘Oral Health’ page 23 for a picture.

2.8 Oral cancer

Oral cancer is al life threatening disease of the mouth. It can occur due to the use of chewing pan, supari, khaini, tobacco smoking and alcohol. These products can cause harmful changes to the tissues of the mouth. Signs or symptoms of oral cancer may be any red or white changes in the mouth or swellings, which in the early stage is painless and stays for a long time.To prevent oral cancer, eat plenty of green vegetables and fresh fruit; do not adopt or try to reduce harmful habits like smoking, drinking alcohol, pan che-wing.

Look in the instruction book ‘Oral Health’ page 25 and 27 for a picture.

2.9 Tooth brushing (including instruction with pictures)

2.9.1 Points for attention

- Why is toothbrushing so important? By toothbrushing you remove bacteria and food particles to prevent tooth

decay and gum diseases.

- How many times a day should you brush your teeth? Brushing should be done at least twice a day. The first time is in the morning

after breakfast, so you remove food particles from your teeth. The second time is in the evening before you going to bed. Brushing in the evening is very important, as there is less saliva flow at night to wash away the food and bacteria.

12

- What should you use to clean your teeth and why? Use a toothbrush. If a toothbrush is not available use a datiwan (twig). This is more effective

than using fingers. Cut a small branch from a tree, which has soft branches such as a sajiwan, coconut, or eucalyptus tree. The small soft branch should be 18 to 20 cm

in length and 1 cm in width (more narrow for children). Remove 2-3 cm of the bark from one end of the stick. Chew this end until it is suitable soft and frayed.

Use toothpaste if available. Fluoridated toothpaste is the best. Fluoride helps the teeth to become strong.

Ground salt mixed with mustard oil can be used if no toothpaste is available. Never use ashes, charcoal, sand, soil, brick-dust or rough powder. These

destroy the white part of your teeth and can cause pain and sensitivity.

Look in the instruction book ‘Oral Health’ page 29 for a picture.

- How should you clean your teeth? The demonstration is based on the ‘tell-show-do method’: the instructor explains the method of brushing (the tell part); the instructor demonstrates it using a large tooth brush (show model)on

the brush model (the show part); the Nepalese people then try by using their own toothbrushes (or datiwan)

in the mouth (without toothpaste) (the do part). Look in a mirror during toothbrushing!

See appendix II for the information sheet with pictures showing how to brush and in which order.

2.9.2 A demonstration of the bass method with the brush model for adults

The bass method concentrates on the lower third part of the tooth nearest to the gum line and the gum itself, where plaque tends to concentrate.Brush gently to avoid damaging the gums.

13

The lower teeth should be cleaned first.Make sure the bristles of the toothbrush point at the edge of the gums at a 45-degree angle.The bristles should cover both your tooth and gum.

Brush gently along the inside tooth surfaces by moving the brush back and forth. Begin at the most posterior molars. Keep the brush touching the tooth and gum. Count 10-15 brush movements before you move on to clean the next section of teeth.Use the brush vertically behind the front teeth. Brush up and down.

www.mondgezondheid.net

www.ivorenkruis.nl

14

Gently brush the outside tooth surfaces of 2-3 teeth using back and forth move-ments. Make sure the bristles of the toothbrush point at the edge of the gums at a 45-degree angle. Move the brush to the next group of 2-3 teeth and do it again.

Brush the chewing surface of the lower molars and bicuspids by moving the brush back and forth for 10-15 seconds on the same section.

15

Now you have finished brushing the lower jaw.Clean the upper teeth in the same way. First the inside, than the outside and finally the chewing surfaces.

After brushing, you should spit out the toothpaste without rinsing with water.

Inside upper jaw outside upper jaw chewing surfaces upper jaw

16

2.9.3 A demonstration of the horizontal scrub method with the brush model for children

This brushing method is for children till 12 years old. Children older than 12 should use the Bass method.

The lower teeth should be cleaned first.Make sure the bristles of the toothbrush are perpendicular at the edge of the gums. The bristles should cover both your tooth and gum.

Brush gently along the inside tooth surfaces by moving the brush shortly back and forth. Start with the most posterior molars. Keep the brush perpendicular touching the tooth and gum. Count 10-15 brush movements before you move on to clean the next section of teeth.Use the brush vertically behind the front teeth. Brush up and down.

www.mondgezondheid.net

www.ivorenkruis.nl

17

Gently brush the outside tooth surfaces of 2-3 teeth using short back and forthmovements. Move the brush to the next group of 2-3 teeth and do it again.

Brush the chewing surface of the lower molars and bicuspids by moving the brush back and forth for 10-15 seconds on the same section.

18

Now you have finished brushing the lower jaw.Clean the upper teeth in the same way. First the inside, than the outside and at last the chewing surfaces.

After brushing, you should spit out the toothpaste without rinsing with water.

Mothers have to assist their children.As soon as the first teeth erupt, clean the baby’s teeth with a soft toothbrush. Stand behind the child and tilt his head upwards so that the teeth can be reached.When the child is old enough to spit, start using a small amount of fluoridated toothpaste on the toothbrush to brush the teeth. Until the time that children can brush their teeth properly (till 12 years), mothers and fathers must assist the children or supervise their brushing. If the parents are too busy to help, an older child of the family can help the younger children.

2.9.4 Use of a datiwan

You can put fluoride toothpaste on the datiwan and brush your teeth as above.

Look in the instruction book ‘Oral Health’ page 31 for a picture.

Inside upper jaw outside upper jaw chewing surfaces upper jaw

19

Chapter 3. Materials and key points to remember when giving oral hygiene information and instruction at primary schools

Materials for the oral health promotion activities

- Instruction book ‘Oral Health’ of United Mission to Nepal (UMN) (or copies if there aren’t sufficient original instruction books).

- Laminated information sheet of brushing (see also appendix II).- Toothbrushes (not a too large brush head!): to buy in Nepal/Kathmandu (a

Nepalees brand).- Toothpaste with fluoride: to buy in Nepal/Kathmandu (a Nepalees brand).- Brush model and a large toothbrush. - Nepalese interpreter (to translate English to Nepalese).

Key points to remember when giving oral hygiene information and instruction at primary schools

- Try en get answers from the Nepalese children by asking questions. For example: Volunteer asks: “What is this?” (show the tooth brush). Nepalese children answer: “A tooth brush”.

- Let the group repeat what you have just told them. If possible, ask open-ended questions.

- Use pictures as often as possible (see instruction book ‘Oral Health’) - When handing out toothbrushes or toothpaste, ask the children to queue or

form a circle. This way you will be able to keep control of the group.- Give the teacher an oral hygiene education guide, an instruction book (or a

copy) and a laminated information sheet of brushing.- Ask the teacher for suggestions and/or additions for the oral hygiene education

guide.

20

Appendix I. Table of activities

Arranging toothbrushes and toothpaste tubes: first ask NOHS if there are enough left from the last Dental Camp. If not, the board of NOHS will ar-range them in Nepal.

Buy the Instruction book ‘Oral Health’. Location of the United Mission to Nepal in Kathmandu: see map on next page.

Metal boxes are available in the Dental Camps which include (among other things):

- a brush model and large toothbrush; - laminated information sheets of brushing.

Extra copies of this guide and more laminated information sheets of bru-shing can be provided by the board of the NOHS.

21

http://www.umn.org.np

1. inside lower jaw 2. outside lower jaw

5. outside upper jaw6. chewing surfaces upper jaw

→→

Appendix II. Information sheet of brushing

23

4. inside upper jaw

3. chewing surfaces lower jaw

→→→

22

Colophon

AuthorIngrid Omlo

AdviserGerjen Winkeler

DesignAngela Bugel

PrinterChesapeake Pharmaceutical and Healthcare Packaging Oss, Netherlands

AdressNOHSp/a Wilhelminastraat 496812 CT ArnhemNetherlands

www.nohs.nl