Running head: HANDS-FREE TOOTHBRUSH

Hands-Free Toothbrush
Jennifer Tom
Touro University Nevada

HANDS-FREE TOOTHBRUSH

Occupational Profile
Client Description and Diagnosis
Richard Devylder was born in 1969 with a congenital defect resulting in missing bilateral
upper and lower limbs. He was born into an Armenian family unwilling to accept his physical
difference, so he was put into foster care and grew up with his foster family. He lives by himself
in a one-story home and has an attendant that comes in to assist with some daily activities such
as meal preparation and assistance in setting up for a shower. He can go to work independently
using public transportation. He enjoys swimming as a part of his daily exercise to prevent back
and neck pain.
Client Occupations and Performance
Richard has learned to use assistive technology to adapt to his environment and
occupations. This enables him to engage and participate in his activities of daily living (ADL)
and instrumental activities of daily living (IADL) independently despite his physical limitations.
He can perform his morning routine using adaptive strategies. For instance, he uses an electrical
shaver independently by having it stabilized in a wooden box drilled into a table. He requires
set-up for oral hygiene. Although he is able to brush his teeth, he must use his shoulders to
stabilize the toothbrush against the sink and may experience difficulty with rotating the
toothbrush if it is not of a particular shape.
Richard is an active member of the community as he can independently use public
transportation to go to the doctors office, work, and to community meetings. At work, he uses a
mouthpiece designed specifically in the contour of his mouth and a voice-activated computer to
complete all of his desk work. Also, he explains that it is important for him to articulate clearly
so others can understand his requests. Maintaining good oral hygiene is important for Richard to
keep his mouth and teeth clean for verbal communication and effective use of a mouthpiece.
Additional Population and Diagnosis

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The targeted population for the proposed Hands-Free Toothbrush are individuals that have
a bilateral loss of motor function in their upper extremities. These individuals face challenges in
their daily independence and interfere with their interaction with their environment (Torres,
Laredo, & Andrew, 2011). Treatment encourages maximum capacity of residue limb function,
total body interaction, and promoting confidence in body image (2011). The proposed HandsFree Toothbrush enable individuals to be more independent on their morning routine and aims to
promote a sense of self-efficacy.
Upper Limb Reduction and Amputations
According to the Centers for Disease Control and Prevention (CDC, 2014), upper and
lower limb reduction is a congenital defect causing an incomplete formation of the extremities.
CDC estimates that roughly 1,500 babies in the United States are born with upper limb
reduction while 750 are born with lower limb reduction. This shows a higher prevalence of
upper limb congenital loss compared to lower limb. Some difficulties these individuals may
encounter are delay in meeting their developmental milestones such as in motor skills, need
assistance with self-care activities and affecting their psychosocial well-being (2014).
While the adapted toothbrush was intended for individuals with bilateral upper extremity
congenital loss, it could also be used for individuals with bilateral upper extremity amputation.
Amputation is a surgical removal of a part or the entire limb (Jain & Robinson, 2008). Upper
limb amputations make up only 3-15% of all amputations. Some causes include trauma,
congenital defect, and cancer. There are different types of upper limb removal such as
amputation of the fingers, hand, forearm, upper arm or shoulder (2008). From the literature
search, Jain and Robinson reported that shoulder disarticulation makes up 5% of all upper limb
amputation, trans-humeral 28%, elbow disarticulation 0.3%, trans-radial 19%, wrist

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disarticulation 2%, partial hand 19%, digit 22%. They suggest that upper limb loss has a more
severe impact on an individuals functional abilities compared to lower extremity loss. This is
because hands and arms are responsible for fine motor skills carried out in many daily activities.
This is further supported by Torres, Laredo, & Andrews (2011) as they explain that a loss of the
hand and portion of the arm affect manipulation, stabilization, and holding of objects. Finally,
the level of amputation is also indicative of an individuals functional abilities (Jain & Robinson,
2008). This indicates that the higher the level of amputation, the greater the impact it has on an
individuals abilities to engage in their daily task. While shoulder disarticulation is less common,
these individuals face greater barriers in completing their daily routine and achieving a quality of
life due to a higher level amputation.
Spinal Cord Injuries
The adapted toothbrush could also be utilized by individuals that had a spinal cord injury
(SCI), specifically at the C4 level. According to the World Health Organization (2013), an
estimate of 250,000 and 500,000 individuals sustained a SCI in the nation annually. Common
causes of SCI are motor vehicle crashes, falls, violence and sporting activities (Torres, Laredo, &
Andrew, 2011). Occupational therapists role for this population include ADL and IADL
retraining, strengthening of key muscles, recommend or design assistive equipment, explore
interests, and psychosocial adjustment (2011). Occupational therapists commonly utilize a
compensatory approach by providing clients with adaptive strategies and recommend
environment modifications to promote independence.
Individuals with a SCI at the C4 level has a loss of bilateral motor and sensory
impairment resulting in upper and lower extremity paralysis (Torres, Laredo, & Andrew, 2011).
They are dependent in self-care activities so it is important for them to be able to verbalize
instructions to caregiver. The key muscles that are still innervated include the upper trapezius,
diaphragm and the accessory and deep neck muscles. This allows them to elevate their

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shoulders, wean off from a breathing ventilator, and can stabilize, rotate, extend and flex their
head (2011). Individuals with C1-C4 tetraplegia requires a caregiver to provide dental care such
as brushing, flossing, and rinsing their mouth. They need to maintain good oral hygiene as they
can still use their teeth and gums to manipulate mouthpieces on different assistive devices
(2011). Therefore, the Hands-Free Toothbrush will be suitable for this population because while
these individuals lack function of their upper and lower extremities, ability in head movement
and use of their teeth enables them to use the Hands-Free Toothbrush to brush their teeth
independently.
Assistive Technology Device
The proposed assistive device is a hands-free toothbrush to enable individuals with motor
deficits in bilateral upper extremities to complete their oral hygiene more independently by
eliminating the requirement of using the upper limbs. The routine practice of proper oral
hygiene has significant contribution in maintaining good health by preventing cavities and
periodontal diseases (CDC, 2009). While oral hygiene has become a familiar and automatic
routine in ones daily life, it poses great challenges for individuals with bilateral upper extremity
disabilities such as stabilization and manipulation of the toothbrush. The proposed device
reduces some of the barriers that individuals with upper limb dysfunction may have in
completing oral hygiene. This in hope would increase their life satisfaction as good dental
hygiene is not only important in keeping the teeth healthy, it also has great implications for
general health and quality of life (Sheiham, 2005).
Traditional toothbrushes require stabilization with one hand. It also requires in-hand and
finger manipulation for rotation of the toothbrush in different angles to brush each tooth with
short back-and-forth strokes. This conventional method is challenging for individuals with upper
extremity dysfunction as they lack the ability to grip and manipulate the toothbrush. The

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proposed hands-free toothbrush empowers the individual to brush their teeth more independently.
This is accomplished by creating a stable foundation to hold the toothbrush so that one can brush
their teeth just by the movement of their head and neck. Mouthpieces are built on the device to
allow the individual to rotate the toothbrush using their chin or any other parts of their body.
Some of the advantages of the adapted toothbrush is the elimination of having to use the
upper extremities to complete oral hygiene, thus increasing independence and self-efficacy.
Additionally, because of the design of the device, it could be easily adapted to hold other items
such as a brush by changing the diameter of the rod that is used to hold and stabilize the
toothbrush.
Literature Review
The following literature review shows that individuals with disabilities lack sufficient
oral hygiene causing adverse outcomes in their oral and periodontal health. Sullivan, Bailey, and
Stokic (2013) conducted a cross-sectional study to examine predictors of oral health for
individuals that sustained a SCI. They reported that these individuals are more prone to
developing oral disease because the use of tobacco is common in this population. Other reasons
include depression, weaknesses in upper extremity motor function and environmental barriers are
all contributing factors to their oral health outcomes. Ninety-two participants were recruited.
The inclusion criteria include sustaining an SCI six months prior to participating in the study,
able to communicate and participate in dental examine, and agree to consent form. Exclusion
criteria include joint replacement within 2 years, history of infectious endocarditis, and heart
conditions. The participants filled out a questionnaire and received an oral examine. The
questionnaire was used to identify the participants socio-demographic status, SCI-related status,
and dental status. To assess oral health, the Oral Health Score (OHS) was utilized to determine
whether the participants had good oral health, not that bad, treatment needed, or

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immediate care is necessary. The Decayed, Missing and Filled Teeth (DMFT) was utilized to
determine the health status of each tooth. Finally, the Periodontal Screen and Recording Index
(PSR) was used to determine periodontal health such as tartar buildup above and below gum,
gingival bleeding, gum recession, and loss of teeth. Only 32% reported having had their teeth
cleaned by a dentist in the past year. Based on the OHS score, only 18% of the participants had
good oral health, 29% were identified as not that bad, 21% were identified as treatment is
needed and 32% were identified as needing immediate care. The DMFT scale showed that the
participants had an average of three decayed teeth, eight missing teeth and four that required
filling. For periodontal health, 64% of the participants required deep scaling. In sum, from the
results, the authors concluded that individuals with SCI have poor oral health.
Another research article addressed oral health according to limbs dysfunction in children
with Poliomyelitis through a clinical examination using Simplified Oral Hygiene Index (OHI-S)
and Community Periodontal Index (Tak, Nagarajappa, Sharda, Asawa, Tak, & Jalihal, 2012).
344 children between the ages of 12-15 years participated in the study. 115 had upper limb
disability, 116 had a lower limb disability and 113 had upper and lower extremity dysfunction.
The OHI-S assess an individuals oral hygiene status and community periodontal index (P)
assess three parts of an individuals periodontal status which include gingival bleeding, calculus
and, periodontal pockets. The average OHI-S score was highest for participants with upper and
lower extremity disability suggesting these individuals have poorer oral status compared to the
other two groups. Results further showed that 83.5% of the participants with upper limb
disability and 85.8% of individuals with upper and lower limb disability were unable to perform
oral hygiene independently. The authors conclude that this population had poor oral health.
Additionally, oral hygiene outcome may be worse depending on which of the limbs are involved.

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In sum, both of the studies show that individuals with some form of motor function
deficits have compromised oral health. This suggests that there is a need for awareness in this
ADL task and creating a device for individuals with upper extremity motor deficit will be
beneficial in their oral hygiene.
Similar Device
A product called Tongue 2 Teeth is also marketed as a hands-free toothbrush created by
Adel Elseri. Tongue 2 Teeth is a plastic contraption worn on the tongue and has what he calls
micropyramids. The micropyramids are little triangular ridges on the contraption to clean the
crevices of the teeth. It is a one-time-use device which prevents bacterial build-up. It is meant
to be used in between brushes such as on the road or on long flights. On his product website, he
explains that there is an interior and exterior coating on the device that kills bacteria on the
tongue, freshens breath and whitens ones teeth website (Elseri, Adel, n.d). Tongue 2 Teeth has
a similar concept to my proposed adapted toothbrush because it does not require the hands to
brush ones teeth. However, my adapted toothbrush is not a one-time use product and is not
mounted on the tongue. Rather, my device was designed to hold and stabilize the toothbrush
and it can be rotated in any desired directions using a mouthpiece built on my device. Elseris
product has been patented and was featured in the news and other forms of media. However,
his product is not yet available for sale but individuals interested in purchasing can leave their
name and email on his website.
Summary
The purpose of the Hands-Free Toothbrush is to enable individuals with bilateral upper
extremity motor deficits to complete their oral hygiene more independently. Some populations
that this device will benefit but not limited to include individuals with a congenital defect
resulting in missing bilateral upper extremities, individuals that had bilateral upper limb
amputation, and individuals with SCI at C4 level. The literature review suggested that people

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with disabilities lack proper oral care. A comparable alternative to the Hands-free Toothbrush is
called Tongue 2 mouth in which the individual put on a plastic contraption on their tongue which
also enables them to brush their teeth without their upper extremities.

Appendix A
Fabricated Device

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Appendix B
Cost Analysis
Quantity
2

Item Description
White rubber leg tips

Cost
$1.98

Vendor
Home Depot

Toothbrushes

$1.98

Dollar Tree

Bar clamps 4x2 in

$9.94

Home Depot

Hex bolt

$0.80

Home Depot

Hex nuts

$0.12

Home Depot

Square black drain grate

$3.74

Home Depot

PVC riser

$1.46

Home Depot

Foam sheet

$0.59

Home Depot

Yellow felt fabric

$0.23

Wal-Mart

Empty badminton shuttlecock tube

$0.00

Already owned

Velcro strips

$2.98

Home Depot
Total Cost: $23.81 + Tax

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Appendix C
Comparable Alternatives
Product

Purpose

Price

Tongue 2 Teeth

Hands-free
toothbrush

Not yet
available for
purchase

Retrieved from
http://www.tonguetoteeth.com/

Picture

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References
Centers for Disease Control and Prevention. (2013). Facts about upper and lower limb reduction
defects. Retrieved from http://www.cdc.gov/ncbddd/birthdefects/ullimbreductiondefects.html
Centers for Disease Control and Prevention. (2009). Dental hygiene. Retrieved from
http://www.cdc.gov/healthywater/hygiene/dental/
Elseri, Adel, (n.d.). Tongue 2 Teeth. Retrieved tonguetoteeth.com
Jain, A. S. & Robinson, P. H. (2008). Upper limb amputation. Retrieved from
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384564/am
putation_upper_limb.pdf
Sheiham, A. (2005). Oral health, general health and quality of life. Bulletin of the World Health
Organization, 83(9). http://dx.doi.org/10.1590/S0042-96862005000900004
Sullivan, A. L., Bailey, J. H., Stokic, D. S., (2013). Predictors of oral health after spinal cord
injury. International Spinal Cord Society. 51, 300-305. doi:10.1038/sc.2012.167
Tak, M., Nagarajappa, R., Sharda, A., Asawa, K., Tak, A & Jalihal, S. (2012).
Comparative assessment of oral hygiene and periodontal status among children who have
poliomyelitis at Udaipur city, Rajasthan, India. Medicina Oral Patol Oral Cir Bucal,
17(6): e-969-e976. doi: 10.4317/medoral.17658
http://dx.doi.org/doi:10.4317/medoral.17658
Torres, Laredo, & Andrew (2011). Spinal Cord Injury. In Christiansen, C.H. & Matuska, K.M
(Eds.). Ways of living: Intervention strategies to enable participation. (4th ed.).
Baltimore, MD: AOTA Press.