506751
research-article2013
NASXXX10.1177/1942602X13506751NASN School NurseNASN School Nurse
Special Needs School Nurses
Oral Hygiene in the Special Needs Classroom Linda Oliva, BSN, RN, NJ-CSN Keywords: oral hygiene; special needs; classroom
H
ealthy People 2020 (healthypeople .gov) lists oral health as one of its leading health indicators. Awareness through education, intervention tactics, and access to services are the encompassing goals. While there has been improvement, there is still an emerging problem of increased decay in the preschool population. It is reasonable to assume that this fact, combined with the additional challenges of children with special needs, offers an area where the school nurse can take an active role in education, prevention, and treatment in special needs students.
Oral Hygiene Challenges and Health Risks in the Special Needs Population According to the National Institute of Dental and Craniofacial Research (2013), delayed or accelerated tooth eruption, bruxism, developmental defects, malocclusion, tooth anomalies, and trauma are all more prevalent in those with special needs. Viral infections, periodontal disease, and gingival overgrowth can also affect oral hygiene. Mattey (2013) discussed several conditions that can cause dental concerns. While these concerns were discussed in relation to the general pediatric population, school nurses who care for children with special needs
should pay particular attention to these possibilities because of the increased risk that their students have. For example, medications such as phenytoin to control seizures can cause gingival hyperplasia, which is a condition where the gums can grow over the teeth. Chronic and long-term health problems, for example, those related to immune suppression, can increase bacterial growth leading to increased dental caries and infections of the gums. Nutritional issues can precipitate such conditions as hypocalcification, which appears as white opaque patches on the teeth. These are just a few conditions that can cause a multitude of problems that can arise with inadequate oral hygiene. Oral health care provider Dr. Scott Navarro, DDS (2007), has addressed the added concerns of sensory integration problems, motor skills, and cognitive ability as contributing factors in the ability of special needs children and their families’ effectiveness to perform proper hygiene. Those who work with children with special needs are aware that many students have difficulty tolerating a toothbrush in their mouths or have difficulty with textures and flavors of toothpaste. Many need special assistance or devices to properly use a toothbrush and may need an adaptive device. Helping students to understand the importance of oral hygiene and then guiding them to achieve necessary oral care skills can present a unique set of challenges.
DOI: 10.1177/1942602X13506751 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2013 The Author(s)
Oral Hygiene Education for Nurses In 2009, the Department of Health & Human Services and the Institute of Medicine convened a panel to explore ways to improve oral hygiene interventions and oral hygiene literacy in the overall population (Jablonski, 2012). One area the committee explored was the important contributions that nondental clinicians make to the prevention, diagnosis, and treatment of oral diseases. Regarding nursing, they specifically examined before-licensure nursing textbooks and discovered that the information was variable, erroneous, and outdated, and content averaged about 0.6%. The research summarizes that “oral health and hygiene has been an area overlooked in overall nursing education, but the growing body of research linking poor oral health to systemic diseases merits the need for added emphasis on the provision of oral hygiene.” Nurses who need information about oral hygiene have several reliable and accessible resources. A primary resource for school nurses is the Oral Health Connections website (NASN, 2013a). This website is a collaboration of NASN and the American Dental Association (ADA) to support school nurses in oral hygiene awareness in the school setting. This site offers many resources, including a health curriculum, parent information, education, forums, links for free publications, and a special needs section.
November 2013 | NASN School Nurse 281
There is also a self-assessment tool for school nurses for baseline knowledge assessment. Members of NASN can join the Oral Health Forum at the NASN website, where they can consult with other school nurses on oral health issues. Recent discussions (NASN, 2013b) have touched on information for free dental services for at-risk teens, a link to access the most recent oral health guidelines for children with disabilities, and a link to an article discussing how the Affordable Care Act might affect dental benefits for children. A search of the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, and the ADA provides research-based information on dental health. Many popular companies that sell dental hygiene supplies offer free teaching materials for students and families on their websites. These companies may have links for school nurses to apply for free tooth brushing and toothpaste kits. Nurses may also find discounted supplies in school nurse catalogs. An Internet search with keywords toothpaste and toothbrushes in bulk will provide nurses with various possibilities within their school’s budget. Occasionally, dentists whose practice may focus on children with special needs might be willing to donate supplies.
Nursing Intervention School nurses’ daily interactions with students put them in a prime position to address oral hygiene. School nurse initiatives can range anywhere from basic education for students and/or families to initiating a brushing program at school, for an entire class or for select students. While typical school-age children may have a curriculum addressing oral hygiene, they do not typically brush their teeth at school unless special circumstances exist. But since students with special needs are at higher risk, an oral hygiene program built into their activities of daily living skills program would benefit them. Nursing observation as well as family assessment and interviewing can help the school nurse to determine which students would
282 NASN School Nurse | November 2013
benefit from school oral hygiene intervention. Nurses whose schools have access to occupational therapists can request assistance for students with motor impairment and sensory issues. Classroom aides can assist with a daily schedule of oral hygiene with appropriate students. A team approach led by the school nurse would have the most impact for a successful program. School nurses also would be prudent to become familiar with the dental services in the home communities of their students. Many parents will ask for assistance, for example, in finding a dental professional with experience in the special needs population. Networking with other school nurses and pediatric nurses can increase our database. Internet searching may further provide resources. Oral Health Connections (NASN, 2013a) has a link for provider care, which school nurses may find of value. A major roadblock for some caregivers might be financial resources; so once again, nurses would be prudent to have some understanding of the financial arrangements accepted by some of the providers. For example, in the past, Medicaid reimbursement has been a significant issue.
Setting up a Brushing Program and Storage of Supplies Teachers typically do not have information regarding oral hygiene supply storage, so this is an area in which school nurses can be proactive. According to the CDC (2011), limited research suggests that even after toothbrushes are rinsed visibly clean, they may contain contamination with potential pathogens. There are no published research data that show brushing with a contaminated toothbrush can cause adverse oral or systemic health effects. Yet, the CDC as well as the ADA’s (2011) position statement offer specific recommendations for the cleaning and storage of toothbrushes. Given that the classroom census may be a few or many students in each room, school nurses would be well-advised to understand these recommendations and how they
decrease the risk of contamination. In addition, staff instruction is paramount, since they will be monitoring and assisting with the daily oral hygiene of students. The CDC (2011) guidelines are as follows: •• Each student should have his or her own toothbrush clearly marked with his or her name. •• Brushes should be changed every 3 to 4 months of regular use, or when bristles become worn. •• Brushes should be rinsed thoroughly after each use. •• Brushes must air dry and be stored in an upright position. Covers should not be used as this encourages moisture and bacterial growth. •• Toothbrushes should never be touching each other. •• It is not necessary to soak toothbrushes in disinfecting solutions or mouthwash. This can actually lead to cross-contamination when used over a period of time, and there is no evidence-based research to support this as being effective. •• If the class is using a communal tube of toothpaste, the paste should be placed in individual dots on a paper plate, paper towel, or wax paper for dispensing. Toothpaste from a communal tube should never be placed directly on brushes. There are many toothbrush holders available in school nurse supply catalogs. If budget is a concern, nurses can devise a holder inexpensively by using a plastic shoebox container. Holes can be made in the lid, and each toothbrush can be placed standing up in each hole. Paper towels placed in the box to catch moisture can be changed as needed. These guidelines can be given to teachers to keep on hand as a reminder of proper storage.
Summary School nurses are faced with so many child health concerns that they may feel overwhelmed with meeting needs. Once a need is identified and a simple plan for daily oral hygiene is set up within the
classroom, this intervention (with appropriate supports) can make a major contribution to the overall health of many students. It is an excellent opportunity for school nurses to have a major impact in carrying out one of the key objectives of The Healthy People Initiatives in the pediatric special needs school setting. ■
Centers for Disease Control and Prevention. (2011). The use and handling of toothbrushes. Retrieved from http://www.cdc.gov/ oralhealth/infectioncontrol/factsheets/ toothbrushes.htm
Acknowledgments
Mattey, E. (2013). Growth and development: Preschool through adolescence. In J. Selekman (Ed.), School nursing, a comprehensive text (2nd ed., pp. 343-345). Philadelphia, PA: F. A. Davis.
The author expresses gratitude to the following colleagues for their editing support and assistance: Cheryl R. Brubaker, MSN, cFNP; Lindsey Minchella, MSN, RN, NCSN; Stephanie M. Porter, MSN, RN; and Susan Zacharski, MEd, BSN, RN.
References American Dental Association. (2011). Statement on toothbrush care: Cleaning, storage and replacement. Retrieved from http://www.ada. org/1887.aspx
Jablonski, R. A. (2012). Oral health and hygiene content in nursing fundamentals textbooks. Nursing Research and Practice. Retrieved from http://www.ncbi.nlm. nih.gov/pmc/articles/PMC3337500/ doi:10.1155/2012/372617
National Association of School Nurses. (2013a). Oral health connections: Linking school nurses to health and wellness resources. Retrieved from http://www. oralhealthconnections.org/Home National Association of School Nurses. (2013b). Oral health forum. Retrieved from http://www.nasn.org/MemberCenter/ DiscussionLists/OralHealthForum National Institute of Dental and Craniofacial Research, National Institutes of Health.
(2013). Oral conditions in children with special needs; a guide for health care providers. Retrieved from http:// www.nidcr.nih.gov/OralHealth/ OralHealthInformation/ChildrensOralHealth/ OralConditionsChildrenSpecialNeeds.htm Navarro, S. (2007). Special needs children need special dental care. Retrieved from http://www.schoolnursenews.org/ BackIssues/2007/0307/OralHealth0307.pdf
Linda Oliva, BSN, RN, NJ-CSN School Nurse Gateway School Carteret, NJ Linda is the school nurse at the Gateway School in Carteret, New Jersey, a private special needs school for students with classifications of multiply disabled, cognitive impairment, autism, and other intellectual disabilities.
IN PROGRESS
November 2013 | NASN School Nurse 283
research-article2013
NASXXX10.1177/1942602X13506751NASN School NurseNASN School Nurse
Special Needs School Nurses
Oral Hygiene in the Special Needs Classroom Linda Oliva, BSN, RN, NJ-CSN Keywords: oral hygiene; special needs; classroom
H
ealthy People 2020 (healthypeople .gov) lists oral health as one of its leading health indicators. Awareness through education, intervention tactics, and access to services are the encompassing goals. While there has been improvement, there is still an emerging problem of increased decay in the preschool population. It is reasonable to assume that this fact, combined with the additional challenges of children with special needs, offers an area where the school nurse can take an active role in education, prevention, and treatment in special needs students.
Oral Hygiene Challenges and Health Risks in the Special Needs Population According to the National Institute of Dental and Craniofacial Research (2013), delayed or accelerated tooth eruption, bruxism, developmental defects, malocclusion, tooth anomalies, and trauma are all more prevalent in those with special needs. Viral infections, periodontal disease, and gingival overgrowth can also affect oral hygiene. Mattey (2013) discussed several conditions that can cause dental concerns. While these concerns were discussed in relation to the general pediatric population, school nurses who care for children with special needs
should pay particular attention to these possibilities because of the increased risk that their students have. For example, medications such as phenytoin to control seizures can cause gingival hyperplasia, which is a condition where the gums can grow over the teeth. Chronic and long-term health problems, for example, those related to immune suppression, can increase bacterial growth leading to increased dental caries and infections of the gums. Nutritional issues can precipitate such conditions as hypocalcification, which appears as white opaque patches on the teeth. These are just a few conditions that can cause a multitude of problems that can arise with inadequate oral hygiene. Oral health care provider Dr. Scott Navarro, DDS (2007), has addressed the added concerns of sensory integration problems, motor skills, and cognitive ability as contributing factors in the ability of special needs children and their families’ effectiveness to perform proper hygiene. Those who work with children with special needs are aware that many students have difficulty tolerating a toothbrush in their mouths or have difficulty with textures and flavors of toothpaste. Many need special assistance or devices to properly use a toothbrush and may need an adaptive device. Helping students to understand the importance of oral hygiene and then guiding them to achieve necessary oral care skills can present a unique set of challenges.
DOI: 10.1177/1942602X13506751 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2013 The Author(s)
Oral Hygiene Education for Nurses In 2009, the Department of Health & Human Services and the Institute of Medicine convened a panel to explore ways to improve oral hygiene interventions and oral hygiene literacy in the overall population (Jablonski, 2012). One area the committee explored was the important contributions that nondental clinicians make to the prevention, diagnosis, and treatment of oral diseases. Regarding nursing, they specifically examined before-licensure nursing textbooks and discovered that the information was variable, erroneous, and outdated, and content averaged about 0.6%. The research summarizes that “oral health and hygiene has been an area overlooked in overall nursing education, but the growing body of research linking poor oral health to systemic diseases merits the need for added emphasis on the provision of oral hygiene.” Nurses who need information about oral hygiene have several reliable and accessible resources. A primary resource for school nurses is the Oral Health Connections website (NASN, 2013a). This website is a collaboration of NASN and the American Dental Association (ADA) to support school nurses in oral hygiene awareness in the school setting. This site offers many resources, including a health curriculum, parent information, education, forums, links for free publications, and a special needs section.
November 2013 | NASN School Nurse 281
There is also a self-assessment tool for school nurses for baseline knowledge assessment. Members of NASN can join the Oral Health Forum at the NASN website, where they can consult with other school nurses on oral health issues. Recent discussions (NASN, 2013b) have touched on information for free dental services for at-risk teens, a link to access the most recent oral health guidelines for children with disabilities, and a link to an article discussing how the Affordable Care Act might affect dental benefits for children. A search of the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, and the ADA provides research-based information on dental health. Many popular companies that sell dental hygiene supplies offer free teaching materials for students and families on their websites. These companies may have links for school nurses to apply for free tooth brushing and toothpaste kits. Nurses may also find discounted supplies in school nurse catalogs. An Internet search with keywords toothpaste and toothbrushes in bulk will provide nurses with various possibilities within their school’s budget. Occasionally, dentists whose practice may focus on children with special needs might be willing to donate supplies.
Nursing Intervention School nurses’ daily interactions with students put them in a prime position to address oral hygiene. School nurse initiatives can range anywhere from basic education for students and/or families to initiating a brushing program at school, for an entire class or for select students. While typical school-age children may have a curriculum addressing oral hygiene, they do not typically brush their teeth at school unless special circumstances exist. But since students with special needs are at higher risk, an oral hygiene program built into their activities of daily living skills program would benefit them. Nursing observation as well as family assessment and interviewing can help the school nurse to determine which students would
282 NASN School Nurse | November 2013
benefit from school oral hygiene intervention. Nurses whose schools have access to occupational therapists can request assistance for students with motor impairment and sensory issues. Classroom aides can assist with a daily schedule of oral hygiene with appropriate students. A team approach led by the school nurse would have the most impact for a successful program. School nurses also would be prudent to become familiar with the dental services in the home communities of their students. Many parents will ask for assistance, for example, in finding a dental professional with experience in the special needs population. Networking with other school nurses and pediatric nurses can increase our database. Internet searching may further provide resources. Oral Health Connections (NASN, 2013a) has a link for provider care, which school nurses may find of value. A major roadblock for some caregivers might be financial resources; so once again, nurses would be prudent to have some understanding of the financial arrangements accepted by some of the providers. For example, in the past, Medicaid reimbursement has been a significant issue.
Setting up a Brushing Program and Storage of Supplies Teachers typically do not have information regarding oral hygiene supply storage, so this is an area in which school nurses can be proactive. According to the CDC (2011), limited research suggests that even after toothbrushes are rinsed visibly clean, they may contain contamination with potential pathogens. There are no published research data that show brushing with a contaminated toothbrush can cause adverse oral or systemic health effects. Yet, the CDC as well as the ADA’s (2011) position statement offer specific recommendations for the cleaning and storage of toothbrushes. Given that the classroom census may be a few or many students in each room, school nurses would be well-advised to understand these recommendations and how they
decrease the risk of contamination. In addition, staff instruction is paramount, since they will be monitoring and assisting with the daily oral hygiene of students. The CDC (2011) guidelines are as follows: •• Each student should have his or her own toothbrush clearly marked with his or her name. •• Brushes should be changed every 3 to 4 months of regular use, or when bristles become worn. •• Brushes should be rinsed thoroughly after each use. •• Brushes must air dry and be stored in an upright position. Covers should not be used as this encourages moisture and bacterial growth. •• Toothbrushes should never be touching each other. •• It is not necessary to soak toothbrushes in disinfecting solutions or mouthwash. This can actually lead to cross-contamination when used over a period of time, and there is no evidence-based research to support this as being effective. •• If the class is using a communal tube of toothpaste, the paste should be placed in individual dots on a paper plate, paper towel, or wax paper for dispensing. Toothpaste from a communal tube should never be placed directly on brushes. There are many toothbrush holders available in school nurse supply catalogs. If budget is a concern, nurses can devise a holder inexpensively by using a plastic shoebox container. Holes can be made in the lid, and each toothbrush can be placed standing up in each hole. Paper towels placed in the box to catch moisture can be changed as needed. These guidelines can be given to teachers to keep on hand as a reminder of proper storage.
Summary School nurses are faced with so many child health concerns that they may feel overwhelmed with meeting needs. Once a need is identified and a simple plan for daily oral hygiene is set up within the
classroom, this intervention (with appropriate supports) can make a major contribution to the overall health of many students. It is an excellent opportunity for school nurses to have a major impact in carrying out one of the key objectives of The Healthy People Initiatives in the pediatric special needs school setting. ■
Centers for Disease Control and Prevention. (2011). The use and handling of toothbrushes. Retrieved from http://www.cdc.gov/ oralhealth/infectioncontrol/factsheets/ toothbrushes.htm
Acknowledgments
Mattey, E. (2013). Growth and development: Preschool through adolescence. In J. Selekman (Ed.), School nursing, a comprehensive text (2nd ed., pp. 343-345). Philadelphia, PA: F. A. Davis.
The author expresses gratitude to the following colleagues for their editing support and assistance: Cheryl R. Brubaker, MSN, cFNP; Lindsey Minchella, MSN, RN, NCSN; Stephanie M. Porter, MSN, RN; and Susan Zacharski, MEd, BSN, RN.
References American Dental Association. (2011). Statement on toothbrush care: Cleaning, storage and replacement. Retrieved from http://www.ada. org/1887.aspx
Jablonski, R. A. (2012). Oral health and hygiene content in nursing fundamentals textbooks. Nursing Research and Practice. Retrieved from http://www.ncbi.nlm. nih.gov/pmc/articles/PMC3337500/ doi:10.1155/2012/372617
National Association of School Nurses. (2013a). Oral health connections: Linking school nurses to health and wellness resources. Retrieved from http://www. oralhealthconnections.org/Home National Association of School Nurses. (2013b). Oral health forum. Retrieved from http://www.nasn.org/MemberCenter/ DiscussionLists/OralHealthForum National Institute of Dental and Craniofacial Research, National Institutes of Health.
(2013). Oral conditions in children with special needs; a guide for health care providers. Retrieved from http:// www.nidcr.nih.gov/OralHealth/ OralHealthInformation/ChildrensOralHealth/ OralConditionsChildrenSpecialNeeds.htm Navarro, S. (2007). Special needs children need special dental care. Retrieved from http://www.schoolnursenews.org/ BackIssues/2007/0307/OralHealth0307.pdf
Linda Oliva, BSN, RN, NJ-CSN School Nurse Gateway School Carteret, NJ Linda is the school nurse at the Gateway School in Carteret, New Jersey, a private special needs school for students with classifications of multiply disabled, cognitive impairment, autism, and other intellectual disabilities.
IN PROGRESS
November 2013 | NASN School Nurse 283
