CASES OF ORAL

HYGIENE
INSTRUCTIONS
L I L L I E C . J O N E S
D E P A R T M E N T O F A L L I E D H E A L T H , M I S S O U R I
S O U T H E R N S T A T E U N I V E R S I T Y
D H 1 2 0 : D E N T A L H Y G I E N E C O N C E P T S
M R S . C H R I S T I A N
M A R C H 0 3 , 2 0 2 3
PAT I E N T 1 ( J A N E D O E ) 1 & 2
Patient: Female, 76 years old

Chief Complaint: “My gums are very sensitive when I brush them. I also find it
hard to clean around my crowns.”

Background/Patient History:

• ASA I
• Routine visits to the dentist (every 6 months)
• Brushes twice a day (after breakfast and before bed)
• Doesn’t like to floss
• Maintains a healthy diet
• Limited dexterity in hands/grasp
Clinical Findings:

• Crowns on tooth #s 5 and 21

• 2-3 mm pockets with healthy, intact periodontium
• Generalized slight papillary inflammation
• Localized Class II embrasures on the distal and mesial sides of crowns
• Generalized light plaque
• Generalized light supragingival and subgingival interdental calculus
(Okamura 1 & Roy 2 )
R E C O M M E N D AT I O N S F O R J A N E D O E
• Modified Bass method
• Manual or powered toothbrush based on patient preference
• Manual toothbrush with angled bristles and thick handle design:
• Bristle design is effective at reaching under and around crowns
• Handle is easier to grasp and is slip resistant
• Helpful for those with limited dexterity
• Rechargeable, oscillating powered toothbrush with bi-level/round angled bristles:
• Head motion and bristle design are effective in plaque and calculus reduction of up to 10-20% more than the
manual toothbrush
• Naturally has a thick handle
• Toothbrush head can be replaced
• Pressure sensor alerts the user when excessive pressure is applied
• Built-in timer ensures the user brushes for, at least, 2 minutes
• Extra-soft bristles to help reduce gingival sensitivity
• End-rounded, nylon/synthetic bristles will ensure no jagged/sharp bristles
(Pg. 433-454)
R E C O M M E N D AT I O N S F O R J A N E D O E
C O N T.
• Countertop power-driven water flosser (Waterpik):
• Thick handle for those with limited dexterity
• Different delivery tip styles for specified needs
• Standard or subgingival are preferred for Jane Doe
• Standard tip can penetrate 44-71% of the pocket
depth
• Subgingival tip can penetrate 41-90% of the pocket
depth, dependent upon the technique used and
calculus presence
• Works well to clean open embrasures and reduce
inflammation
• Water stream can be directed to go under and around
crowns

(pg. 455-469 & Redd 3 )

MODIFIED BASS
METHOD
• Sulcular brushing technique that includes a rolling
(flick-like) motion:
• Deemed worthy for the removal of plaque as deep as
0.9 mm in the sulcus and from marginally adjacent
areas
• Indicated use on patients who have:
• Intact or unhealthy periodontium
• Open embrasures
• Difficulty reaching the cervical areas below the
CEJ
• Exposed roots
• Difficulty adapting to and cleaning under the
gingival border of dental prostheses

(Pg. 433-454)
MODIFIED BASS METHOD
INSTRUCTIONS
• 1. Choose which arch to start with

• 2. Position the side of the bristles of the brush head apically (towards the gingiva) and parallel to the tooth’s long axis for that
arch
• 3. Turn the brush head to a 45-degree angle to the tooth’s long axis, so that it faces the gingival margin

• 4. With light pressure, gently slide the filament tips into the sulcus and embrasures until they cover the gingival margin

• 5. With very short strokes, vibrate the brush head back and forth while making sure not to dislodge the filament tips from the
sulci
• 6. Do 10 vibration strokes

• 7. Vibratory strokes should then be followed by rolling the toothbrush down towards the crown’s occlusal edge in order to
clean the remaining tooth surface
• 8. Move the toothbrush to the next 2-3 teeth, making sure to overlap placement

• 9. When brushing the lingual/palatal anterior tooth surfaces, vertically tilt the brush handle so the bristles enter the sulci.

• 10. Repeat steps 2-9 until all tooth surfaces of each arch have been cleaned and have been brushing for a total of 2 minutes
(Pg. 433-454)
POWERED TOOTHBRUSH
INSTRUCTIONS
• Use will follow steps 1-4 as explained for the modified Bass
method, but minor differences will be applied:
• Differences:
• 1. After placing the bristles on the tooth, turn on the brush to
low speed
• 2. Covering one tooth at a time, move the toothbrush head
across the buccal, lingual, and interproximal surfaces for 5
seconds
• 3. Systematically reposition the toothbrush onto the next
tooth
• 4. Repeat steps 1-2 on the next tooth
• 5. Brush until the built-in 2-minute timer ends

(Zoellner 4 & Pg. 433-454)

C O U N T E R T O P P O W E R - D R I V E N WAT E R P I K

• Pressurized, pulsated or steady water stream that reduces • Indicated use on patients who have:
bacteria/inflammatory mediators and can be incorporated • Inflammation
into a daily self-care routine
• Open interdental/embrasure spaces
• Removes supragingival interdental plaque, which helps • Malpositioned teeth
reduce inflammation
• Exposed furcations
• Has different delivery tips • Dental prostheses
• Standard • Orthodontic appliances (braces)
• Subgingival • Extensive rehabilitation and fixation
• Orthodontic appliances for jaw surgery
• Filament-type • Ineffective/irregular interdental cleaning
methods

(455-469 & Redd 3 )

WA T E R P I K I N S T R U C T I O N S
• 1. Fill up water reservoir
• 2. Select the appropriate delivery tip
• 3. Place the tip toward the interdental/embrasure space and as close to the tooth
surface without touching it
• 4. Turn the tip to a 90-degree angle to the tooth’s long axis to begin removing
supragingival debris and loosen the plaque
• 5. Bend over sink to reduce the splash/splatter mess that will be created
• 6. Turn unit on to low power and increase pressure to one that is most comfortable
• 7. Systematically floss all surfaces of the teeth by going from one side of the
maxillary arch to the other (facial and lingual surfaces) and then move onto the
mandibular arch
• 8. Empty water reservoir once flossing is complete and put away

(
Waterpik® Oral Health 5 &Pg. 455-469)
OHI INSTRUCTIONS FOR JANE
DOE
• Understanding the toothbrush and interdental aid instructions may be difficult, so I will provide Mrs. Doe with a
demonstration to show her how to properly use the technique.
• Mrs. Doe is a good and consistent brusher. I recommend that she start using the modified Bass method with an extra-soft
bristled toothbrush twice a day for, at least, 2 minutes to continue the biofilm disruption. She should use toothpaste
(dentifrice) with minimal abrasivity and stannous fluoride to help reduce the dental biofilm and inflammation.
• Which toothbrush she uses is up to her, but the powered brush is preferred. It will help with her limited dexterity, since it
limits the amount of physical pressure she applies with her hands. The powered toothbrush will also provide the
vibratory stroke for her, which will ease the strain on her hands/grasp.
• She will need to let her toothbrush air dry thoroughly in an open container with its head facing the sky and not touching
other items around it.
• The toothbrush, or toothbrush head, must be replaced every 2-3 months and thoroughly cleaned of all visible debris after
every use. This will prevent excessive bacteria accumulation and loss of effectiveness during use.
• I would recommend that she incorporates the Waterpik into her daily brushing routine and use low pressure as to not
irritate her gingiva. She should use it twice a day until each interdental area has been cleaned. I would also suggest that
she use it around and below her crowns to help clean out any debris and calculus that may be trying to accumulate in
those areas.
PAT I E N T 2 ( J O H N D O E )
Patient: Male, 12 years old

Chief Complaint: “My back teeth hurt when I eat food.”

Background/Patient History:
• ASA II
• Developed mild asthma at 10 years old
• First visit to the dentist was one year ago
• Doesn’t brush
• Uses a mouthrinse twice a day (after breakfast and before bed) as a replacement
• Flosses after every meal
• Frequent intake of sweet treats and sugary beverages
Clinical Findings:
• Xerostomia from inhaler use
• 4 mm pseudopockets with no visible bone loss on radiographs
• Diagnosed caries that have progressed to an advanced Class 1 on tooth #s 2, 14, 18, 19, and
30
• Generalized moderate marginal inflammation
• Generalized Class I embrasures with minimal papillary loss
• Generalized heavy supragingival and subgingival plaque and calculus
(Berg 7 & Pg. 455-469)
R E C O M M E N D AT I O N S F O R J O H N
DOE
• Modified Stillman method and occlusal brushing (chpt. 26)
• Manual toothbrush with multilevel bristles and a pleasing, non-slip,
lightweight design:
• Bristle design is effective at reaching into occlusal surfaces (pits and
fissures)
• Handle is slip resistant and doesn’t feel bulky/tiresome to use
• Pictures can be placed on the handle to entice and gain attention
• Inexpensive and durable
• Damaging it won’t be as costly as compared to a powered
toothbrush
• Soft bristles to help minimize gingival irritation and enamel damage,
especially in cavitated areas
• End-rounded, nylon/synthetic bristles will ensure no jagged/sharp bristles

(Pg. 433-454)
R E C O M M E N D AT I O N S F O R J O H N D O E
C O N T.
• Disposable rubber interdental cleaner:
• First choice, along with other interdental brushes, for
interdental/embrasure cleaning
• Thin diameter allows easy access into open embrasures, unlike floss
• Flexibility reduces risk of breakage
• Elastomeric extensions on tip help fill the interdental/embrasure
space
• Effective in removing interdental plaque and reducing gingival
bleeding
• Good applicators of therapeutic agents, such as desensitizing and
anticaries agents

(GUM 8 & Pg. 455-469)

MODIFIED STILLMAN METHOD
• Sulcular brushing technique that includes a rolling (flick-like) motion:
• Designed to massage, stimulate, and clean the cervical areas of the teeth
• Removes plaque below the teeth’s height of contour and from exposed interdental
surfaces
• Indicated use on patients who have:
• Ginigva that are irritated and lack sufficient blood flow
• Difficulty removing plaque from the teeth’s cervical areas

(Pg. 433-454)
MODIFIED STILLMAN METHOD
INSTRUCTIONS
• 1. Choose which arch to start with

• 2. Position the side of the bristles of the brush head on the attached gingiva and direct them apically (towards the gingiva)

• 3. Bristle ends should cover part of the gingiva and part of the tooth’s cervical area (slightly above the gingival margin)

• 4. Apply light pressure to the toothbrush head to flex the bristles against the gingiva until the tissue blanches

• 5. Turn the brush head to a 45-degree angle to the tooth’s long axis

• 6. With light pressure, make small rotary/vibrating strokes with the bristles adapted to the tooth surface and count to 10

• 7. Begin to roll the bristles down the tooth by moving the toothbrush head toward the tooth’s edge, while making sure the bristles reach
into the interdental spaces

• 8. Lift the toothbrush and repeat steps 2-7 five times on the same tooth/group of teeth

• 9. Move the toothbrush to the next 2-3 teeth, making sure to overlap placement

• 10. When brushing the lingual/palatal anterior tooth surfaces, vertically tilt the brush handle so the bristles cover the attached gingiva and
cervical area of the tooth

• 11. Repeat steps 2-10 until all tooth surfaces of each arch have been cleaned and have been brushing for a total of 2 minutes
(Pg. 433-454)
OCCLUSAL BRUSHING
• Little circular/vibrating strokes applied to the occlusal surfaces of the teeth with light pressure
• Bristles remaining on the occlusal surfaces allows their tips to reach into the pits and fissures of the teeth
• Effective at loosening debris and microorganisms that may induce caries in the pits and fissures
• Removal of plaque along the margins of the occlusal surfaces and/or restorations is easily achieved
• Indicated use on patients who have:
• Deep pits and fissures
• High risk of caries development within the occlusal surfaces of teeth
• Occlusal restorations

(Pg. 433-454)
OCCLUSAL BRUSHING
INSTRUCTIONS
• 1. Choose which arch to start with

• 2. Place bristles on the molars’ occlusal surfaces at a 90-degree angle and direct bristle tips into the pits

• 3. Direct toothbrush handle parallel to the occlusal surfaces

• 4. Stretch the end of the toothbrush head (end not connected to the handle) out until it covers the distal grooves of the molars’
occlusal surfaces
• 5. Use one the two acceptable strokes mentioned below:
• Count to 10 as circular movements and vibrations are applied to the occlusal surfaces of 2-3 teeth with moderate pressure
while keeping the bristle tips adapted to the pits and fissures
• Push the bristles into the occlusal surfaces of 2-3 teeth with sharp, fast strokes, lift the toothbrush off of the teeth after
each stroke, and repeat motion 10 times
• 6. Move onto the premolars while making sure to overlap the previous stroke

• 7. Repeat steps 2-5 on premolars

• 8. Move onto the next arch once all posterior teeth have been thoroughly cleaned for a total of 2 minutes
(Pg. 433-454)
D I S P O S A B L E I N T E R D E N TA L
CLEANER
• Similar to interdental brushes, except they are • Indicated use on patients who have:
wireless and made of rubber • Open embrasures with/without attachment
• Easy to use and often preferred by patients loss
• Size of interdental cleaner determined by • Dental prostheses
embrasure space size • Orthodontic appliances

• Can be disposed after use • Space maintainers

• Reduces the risk of reintroducing bacteria • Concave proximal surfaces

to the interdental/embrasure space • Exposed Class IV furcations
• Periodontal disease

(Pg. 455-469)
D I S P O S A B L E I N T E R D E N TA L
CLEANER INSTRUCTIONS
• 1. Choose the cleaner with the appropriate diameter that fills the
embrasure
• 2. Angle it to maintain a parallel relationship with gingival form and
insert it into the embrasure
• 3. Use light pressure to brush in and out of the embrasure, making
sure to brush the mesial and distal proximal surfaces
• 4. Continue to brush until any debris and plaque is completely
removed
• 5. Throw away cleaner after use

(Strange 9
OHI INSTRUCTIONS FOR JOHN
DOE
• I would explain to Mr. Doe that using mouthrinse as a replacement for brushing is not the best idea, since it won’t preserve optimal oral health, won’t drastically
decrease the amount of plaque/calculus accumulation, and it can increase his extent of xerostomia. I would recommend that he brush twice a day for, at least, 2
minutes with the Stillman and occlusal method. He should use a counting system to ensure that he brushes for the full 2 minutes. He can, either, count until 10 strokes
are completed in one area or can count slowly to 10 for each area the strokes are applied.

• I would recommend that he use fluoridated toothpaste (stannous fluoride) with minimal abrasivity to help prevent further caries, desensitize the cavitated teeth, and
reduce any further enamel damage to the teeth.

• Mr. Doe can continue to use the mouthrinse, but should use alcohol free ones to reduce the likelihood of worsening his xerostomia. Use of mouthrinses will also help
in desensitizing the cavitated teeth and reduce inflammation.

• I would explain to Mr. Doe that his inhaler use is the most likely cause of his xerostomia, but he can increase his intake of fluids or chew gum to help increase his
saliva flow.

• Mr. Doe’s frequent intake of sweets and sugary beverages have aided in his caries development, so I would suggest that he cut back on his intake significantly, but not
entirely.

• Understanding the toothbrush and interdental aid instructions may be difficult, so I will provide Mr. Doe with a demonstration to show him how to properly use the
technique.

• He will need to let his toothbrush air dry thoroughly in an open container with its head facing the sky and not touching other items around it.

• The toothbrush must be replaced every 2-3 months and thoroughly cleaned of all visible debris after every use. This will prevent excessive bacteria accumulation and
loss of effectiveness during use.

• Interdental cleaner should be disposed of after every use and cleaned after every interdental area it is used in to minimize bacterial recontamination.
REFERENCES
1
Okamura, K. (2014, March 18). Just What is Dental Plaque? Dr. Kim Okamura DDS. Retrieved March 2, 2023, from
https://kimokamuradds.com/just-what-is-dental-plaque/.
2
Roy, A., Kashyap, B., & Nakra, P. (2019, May). Black Triangles and its Management- A Review. SSR Institute of
International Journal of Life Sciences (SSR-IIJLS). Retrieved March 2, 2023, from
https://iijls.com/currentissue/Html_SSR-IIJLS_1608.htm.
3
Redd, N. (2023, January 27). The Best Water Flossers. The New York Times. Retrieved March 3, 2023, from
https://www.nytimes.com/wirecutter/reviews/best-water-flossers/.
4
Zoellner, D. (2022, November 26). The 6 Best Electric Toothbrushes, Tested in Our Lab. Verywell Health. Retrieved March 3,
2023, from https://www.verywellhealth.com/best-electric-toothbrushes-4571275.
5
Waterpik® Oral Health. (2023). Countertop & Cordless Water Flossers. Waterpik® Oral Health. Retrieved March 2, 2023,
from https://www.waterpik.ca/en/oral-health/countertop-cordless-water-flossers/.
6
Hirsch, D., & Hirsch, M. (2023, March 3). 50 American Candy Favorites. 2foodtrippers. Retrieved March 3, 2023, from
https://www.2foodtrippers.com/best-american-candy/.
7
Berg, J. H. (2022, December 8). Medical Management of Dental Caries: "Be a Knife Doctor and a Pill Doctor". Oral Health
Group. Retrieved March 3, 2023, from
https://www.oralhealthgroup.com/features/medical-management-of-dental-caries-be-a-knife-doctor-and-a-pill-doctor/.
R E F E R E N C E S C O N T.
8
GUM. (2021, August 13). Recommending Interdental Brushes or Picks: What Oral Care Professionals Should Know.
Proud to Care. Retrieved March 3, 2023, from
https://professional.sunstargum.com/en-en/news-events/news/interdental-brush-patient-home-oral-care.html.
9
Strange, M. (2017, February 6). 5 Routine Things We do in the Dental Profession that do not Make Sense. Perio-
Implant Advisory. Retrieved March 3, 2023, from
https://www.perioimplantadvisory.com/clinical-tips/hygiene-techniques/article/16412245/5-routine-things-we-do
-in-the-dental-profession-that-do-not-make-sense
.
Boyd, L. D., Mallonee, L. F., Wyche, C. J., Wilkins, E. M., & Macarelli, C. R. (2021). Oral Infection
Pg. 433-454

Control: Toothbrushes and Toothbrushing. In Wilkins’ Clinical Practice of the Dental Hygienist (13th ed., pp.
433–454). essay, Jones & Bartlett Learning.
Boyd, L. D., Mallonee, L. F., Wyche, C. J., Wilkins, E. M., & Moravec, L. J. (2021). Oral Infection
Pg. 455-469

Control: Interdental Care. In Wilkins’ Clinical Practice of the Dental Hygienist (13th ed., pp. 455–469). essay,
Jones & Bartlett Learning.
Boyd, L. D., Mallonee, L. F., Wyche, C. J., Wilkins, E. M., & Perry, K. (2021). Dentifrices and
Pg. 471-483

Mouthrinses. In Wilkins’ Clinical Practice of the Dental Hygienist (13th ed., pp. 471–483). essay, Jones &