Evaluating oral care for hard-to-reach areas

Evaluating oral care for hard-to-reach areas

This article considers the challenges all patients face when brushing and cleaning interdentally, as well exploring the limitations resulting from reduced dexterity, offering evidence-based solutions to help support their oral health.

This article is equivalent to one hour of Enhanced CPD

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Learning Outcomes: A | C | D

Aims & Objectives

The aim of this article is to consider the challenges all patients face when brushing and cleaning interdentally, as well exploring the limitations resulting from reduced dexterity, offering evidence-based solutions to help support their oral health.

On completing this Enhanced CPD session, the reader will:

  1. Understand why there are limitations to mechanical cleaning
  2. Understand the challenges facing people with reduced dexterity
  3. Understand how to help patients rise above any difficulties they may face when using traditional home-care mechanical cleaning tools
  4. Understand the role that a chemical adjunct may play in overcoming any oral health deficits
  5. Understand that good communication between the patient and dental professional is key to success.

This article considers the challenges all patients face when brushing and cleaning interdentally, as well exploring the limitations resulting from reduced dexterity, offering evidence-based solutions to help support their oral health

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According to Herrera and Serrano (2015), while studies into mechanical cleaning (i.e. tooth brushing and interdental cleaning) have shown its effectiveness in relation to biofilm control, others indicate that, for many people, this alone is not enough to prevent periodontal disease.1

There are a number of possible explanations for the shortcoming associated with mechanical cleaning, such as:

  1. Short brushing time, with the mean average suggesting it does not exceed 37 seconds
  2. Interdental cleaning devices are used by less than 10% of the population
  3. Physical limitations.1

Reduced physical ability

In the UK, 10 million people are affected by disease related to arthritis, with nearly 9 out of 10 diagnosed with osteoarthritis. This condition can make movement more difficult; joints in the hands are commonly affected, which may result in reduced dexterity.2

It has also been reported that there is, ‘…a strong positive relationship between poor oral hygiene and individual dexterity, in elderly individuals.’3

The Cambridge Dictionary defines ‘dexterity’ as, ‘the ability to perform a difficult action quickly and skilfully with the hands.’4

Dexterity and oral health

Barouch and colleagues (2019) assessed patients’ dexterity using the ‘chopstick test’. It involved patients picking up peas using chopsticks and transferring them from one box to another in the space of one minute. The numbers of peas in the second box were then counted.3

They also investigated the possible effect of age, gender and which hand was dominant in relation to oral hygiene.3

However, they found that dexterity was the only ‘significant predictor’ in terms of oral hygiene improvement.3

Offering practical advice, they wrote: ‘Our results indicate that it is important to address dexterity for the quality of plaque control. If patients have poor oral hygiene, their level of dexterity should be determined rather than assuming that it is due to lack of awareness or motivation. The method used in this research proposes an easy test, which can be incorporated into patient assessment, to assess the dexterity status. The dexterity test can be used to assess the level of plaque control, as well as to analyse the reasons for poor oral hygiene.’3

If it is ascertained that a patient has problems with dexterity, as suggested by Dougall and Fiske (2008), adaptations to at-home oral care tools such as toothbrushes and interdental brushes may be needed to minimise the effect of any physical impairment on oral hygiene.5

A number of toothbrush adaptations are available, such as enlarged and elongated handles, to help the user achieve a stable grip and to be able to manipulate the brush in the mouth more effectively.5

In addition, a patient with limited dexterity may find an electric toothbrush easier to use than a manual one, because they tend to have larger diameter handles, making them easier to grip, and the power action may compensate for any loss of ‘skilled manipulation’.5

Traditional toothpaste tubes can also be difficult to use, however there are alternatives such as pumps and dispensers. In addition, some dispense the appropriate amount of paste onto the toothbrush when the dispenser lever is pressed.5

It has been recognised that flossing is a difficult skill that many people find difficult to perform effectively, even without any physical limitations.6

However, when it comes to interdental cleaning, as with toothbrushes, there are a variety of aids are available, some of which are adaptable. These include floss and tape, wood sticks, interdental brushes and interspace brushes.7

Floss holders, for example, may be helpful for patients who cannot floss as a result of dexterity or other physical challenges. Meanwhile, the wide range of interdental brushes available in relation to brush size and handle design means that they can be chosen and adapted to meet patient need.6

In addition, the use of an interdental brush has been shown to be more effective than traditional floss when it comes to removing plaque from areas of recession or partially open or wide embrasures.6

Chemical adjuncts

As already touched upon, irrespective of physical ability, for some people mechanical cleaning is insufficient to achieve a good level of oral health, for a variety of reasons.1

This idea is supported by Boyle and colleagues (2015), who wrote: ‘[…] a very large proportion of plaque on teeth is left behind by most individuals and soft tissues largely untouched by mechanical means of plaque control.’8

Brown and colleagues further suggested that, ‘…chemical adjuncts to aid plaque control may simplify conventional oral hygiene care in situations where difficulties are experienced.’9

This view is also held by Chapple and colleagues (2015), who stated: ‘For the treatment of gingivitis and where improvements in plaque control are required, adjunctive use of antiplaque chemical agents may be considered. In this scenario, mouth rinses may offer greater efficacy but require an additional action to the mechanical oral hygiene regime.’10

In terms of mouthwash formula efficacy, it has been demonstrated that, when used for less than three months, a mouthwash containing chlorhexidine is the most effective in reducing dental plaque.8

Over a period of more than six months, an essential oils mouthwash equalled or exceeded the effect of chlorhexidine in controlling plaque as an adjunct to standard care, without the latter’s potential side effects including tooth staining and changes in taste.8

Adding to the evidence base, Araujo and colleagues’ (2015) meta-analysis indicated that 36.9% of subjects using mechanical methods with essential oil-containing mouthwash experienced at least 50% plaque-free sites after 6 months, compared to just 5.5% of patients using mechanical methods alone.11

For patients who would prefer an alcohol-free variant, Lynch and colleagues’ (2018) randomised controlled clinical study revealed: ‘Alcohol-free and alcohol-containing EO [essential oil] mouthrinses were able to reduce plaque… in comparison to the use of mechanical oral hygiene alone in a six-month, randomized study. No significant differences in efficacy in reducing plaque … [was] found between alcohol containing and alcohol free essential oil mouthrinse formulations.’12

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Moving on the right direction

Of course, all of this requires effective communication between the dental professional and patient if successful changes are to me made.

As Heidari and colleagues wrote: ‘Good communication builds a rapport with the patient and the carer/support worker. This requires clear language, which means no jargon, and sufficient time must be allowed to interact with the patient. An unhurried and calm atmosphere is conducive to reducing anxiety for both patient and operator.’7

Overall, when it comes to oral care, as stated by Sälzer and colleagues (2015), ‘There is not one aid that works for all. There is also not one aid that does not work for anyone. Best care for each patient rests neither in clinician judgement nor scientific evidence but rather in the art of combining the two through interaction with the patient to find the best option for each individual.’13



  1. Herrera D, Serrano J. In: Chemical oral and dental biofilm control. Clinical Periodontology and Implant Dentistry, 2 Volume Set, 6th Edition. Wiley-Blackwell 2015

  2. Accessed 24 January 2020

  3. Barouch K et al. Clinical relevance of dexterity in oral hygiene. BDJ 2019; 226(5): 354-357

  4. Accessed 24 January 2020

  5. Dougall A, Fiske J. Access to special care dentistry, part 4. Education. BDJ 2008; 205(3): 119-130

  6. DeSpain Eden B. Prevention strategies for periodontal disease. In: Prevention in Clinical Health Care. Mosby 2008

  7. Heidari E et al. Oral health promotion for special care patients. Dental Nursing 2016; 12(2): 84-88

  8. Boyle P et al. Mouthwash use and the prevention of plaque, gingivitis and caries. Head & Neck Oral Diseases 2014; 20(1): 1-76

  9. Brown LF et al. Periodontal disease and the special needs patient. Periodontology 2000 2107; 74(1): 182-193

  10. Chapple ILC et al. Primary prevention of periodontitis: managing gingivitis. Clin Periodontol 2015; 42 (Suppl. 16): S71-S76

  11. Araujo MWB et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. JADA 2015; 146(8): 610-622

  12. Lynch MC et al. The effects of essential oil mouthrinses with or without alcohol on plaque and gingivitis: a randomized controlled clinical study. BMC Oral Health 2018; 18: 6-15

  13. Sälzer S et al. Efficacy of inter-dental mechanical plaque control in managing gingivitis – a meta-review. J Clin Periodontol 2015; 42 (Suppl. 16): S92-S105