I CAN BRUSH MY TEETH! TIPS FOR TOOTH BRUSHING AND ORAL CARE!

Tooth brushing is an important aspect of personal hygiene! This post is part of the "Functional Skills for Kids Blog Series" with a look at different forms of personal care.  Make sure you check out all the great tips for hand washing, bathing, showering, nose blowing, hair cuts, sleep, screen-free quiet times as well as adolescent hygiene ..... at the end of this article!
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Dentists worldwide including the America Dental Association and theAustralian Dental Association recommend that children brush their twice a day for two minutes at a time. They also recommend regular visits to the dentist, use of fluoride tooth paste  and daily flossing.  Both of these sites have great resources to encourage your kids to brush and floss! 

Occupational therapists help people to become independent in activities of daily living (ADL). We consider aspects of the activity as well as environmental demands to determine why a child might have difficulty achieving independence in a task. For babies and toddlers, we also consider why they may not want to participate in the task!

​Firstly we may consider the developmental expectations for tooth brushing and some tips to help with these stages. 

Babies  
Aim: Tolerating oral sensation of something in the mouth  and tongue movement.

Tips for helping babies:

• Provide opportunities to mouth safe toys and objects (eg. small spoon).
• Allow your child to play with a child friendly toothbrush - allow exploration.
• Use an adult finger tip tooth brush (eg. made from silicon or rubber) to provide gentle pressure on gums, tongue and lips.
• Toothpaste is not necessary.

Toddlers/preschoolers  
Aim: Tooth brushing and flossing by an adult  and beginning to brush parts themselves

Tips for Toddlers and Preschoolers:

• Use a soft bristle toothbrush and a small amount of fluoride tooth paste (rice grain size for under 3 years and pea-size for 3-6 years) .  
• Allow child to play with the toothbrush and attempt some brushing independently.
• Role play on a doll or teddy.
• Use novelty tooth brushes with your child's favourite character (or ones that light up). Let them choose the tooth brush. 
• Lead by example and demonstrate that you brush your teeth (and care about your teeth).
• Read books about tooth brushing.
• Sing songs about tooth brushing. 
• Provide a mirror so the child can see their mouth during brushing. 
• Whilst it is ok for young children to swallow small amounts of toothpaste, you can practise spitting out small amounts of water. 

​School Age Children
Aim: Independent brushing and flossing teeth. 

Tips for School Age Children

• An electric toothbrush may be motivating for older children.
• Use a kitchen timer, tooth brushing video orapp to encourage 2 minutes of brushing.
• Use a reward chart if necessary. (Download your FREE reward chart here!)
• Practise squeezing the adequate amount of toothpaste.  
• Use a small tube of toothpaste (eg. travel size) to encourage smaller squeezes of paste.
• Use a checklist to mark off each aspect of the tooth brushing routine. (Download your FREE checklist here!)
• Discuss the importance of good dental hygiene and foods to avoid to prevent decay.
• Listen to your dentist's recommendations for  the correct techniques for brushing and flossing. 

Children with special needs may have difficulty with specific aspects of brushing their teeth.  Here are some further considerations for tooth brushing! 

Fine Motor Considerations 

1. Ability to grasp the tooth brush 
2. Unscrew and screw back tooth paste lid 
3. Adequate pressure to squeeze toothpaste
4. Bilateral coordination to  hold tooth brush whilst squeezing tooth paste 
5. ​​Hand control to reach all teeth and gums with the tooth brush 
6. Adequate pressure of the toothbrush on the teeth and gums
7. Manipulation of dental floss to cut a piece 
8. Manipulation of dental floss to wind around fingers 
9. Manipulation of dental floss to floss between teeth 
10. Turning on and off taps  

Tips to Help with Fine Motor Skills

• Use toothpaste in a pump rather than a tube. 
• Use a floss pick rather than dental floss string. You may choose to wash the floss pick as you progress in the mouth and continue to practise using dental floss.
• Use a mirror so your child can see their teeth whilst brushing.

Gross Motor Considerations

1. ​Shoulder stability whilst brushing
2. Core muscle strength to perform task whilst standing
3. Standing to reach the sink and look in the bathroom mirror

Tips to Help with Gross Motor Skills

• Use a stool to help reach the sink.
• Sit down to brush and spit into a bucket or bath. 
• Brush teeth whilst sitting in the bath.

Sensory Considerations
Touch/Proprioception:

• Sensation of the toothbrush bristles on the gums, tongue, lips and inside cheeks
• Texture of the tooth paste
• Pressure applied whilst brushing
• Sensation of foaming from the tooth paste during brushing
• Sensitive gag reflex from toothbrush in mouth
• Desire to bite the toothbrush
• Soft/hard toothbrush bristles
• Alternate toothbrush bristle sensations (eg. silicon, electric toothbrush)
• Awareness (or non-awareness) of toothpaste on chin or face

Some children are hypo-sensitive (under responsive) and others are hyper-sensitive (over responsive) to touch around their mouths and face.  Children who are hypo-sensitive may have low tone and poor awareness of their oral motor muscles.  They may dribble constantly and have difficulty keeping their mouth closed.   Children who are hyper-sensitive may have a pain response to touch around their face and mouth.   Both groups of children may have difficulty with brushing their teeth. 

Smell

• Smell of the tooth paste
• Smell of the bathroom (ie. from the toilet, cleaning disinfectant, air freshener, etc)

Vestibular

• Unable to stand still for two minutes needed to brush teeth
• Constantly changing positions
• Poor body awareness and tooth brush misses mouth during brushing 
• Poor balance with child falling over during tooth brushing

Auditory

• The sound of the toothbrush

Oral/Taste

• The taste of the tooth paste (often mint flavoured)
• Difficulty closing mouth during brushing (so tooth paste dribbles down chin)
• Difficulty with keeping tooth paste in mouth without swallowing
• Refusing to place tooth brush in mouth
• Constant tongue movement during  brushing
• Desiring to brush areas external to mouth (eg. lips, cheeks, jawline)

Tips to Help With Sensory Processing Skills
Your child may benefit from an oral desensitization program as part of a sensory diet.   This might involve increasing deep pressure to the jaw, lips, cheeks, tongue and mouth.  

Bundy, Lane and Murray (2002) recommend providing infants and young children with deep pressure to the roof of the mouth or gums with the therapist's fingers or other soft rounded object (eg. Nuk toothbrush).  They also suggest that older children and adults may be taught to provide deep pressure to their own mouths using a variety of oral motor toys (eg. using whistle, biting on knotted rubber tubing, blowing on a rubber strip).   

The Paediatric Occupational Therapy Department from Abertawe Bro Morgannwg University Health Board (2014) describe a protocol of oral desensitisation. This includes the following progressive steps:

1. ​​Apply firm pressure symmetrically to the area outside the child's mouth (from the forehead to the chin and mouth) using hands or different materials. 
2. Encourage your child to apply pressure (massage) to the roof of their mouth and gums (with their finger or a soft, round object).  This may begin with placing the child's finger on their lips and then  by rolling the finger inside the lip.
3. Encourage the child to dip the end of the toothbrush into a small cup of water and brush their tongue, teeth, inside of the cheeks and roof of the mouth.   Additional input with an electric toothbrush may provided. 
4. When the child is coping well with touch to their face and inside of their mouth, further oral motor activities may be introduced involving sucking, blowing, biting, crunching, chewing or licking. 

Further information about this protocol may be found here. 

You may also like to try...

• "Chewlery" or chewable jewellery to provide self regulating oral input. 
• A DIY "oral motor toy" to encourage blowing .
• Breakfast smoothies to awaken oral senses!

Attention and Behavior Considerations 

• ​Remembering the sequence of the task prior to brushing (ie. putting tooth paste on, wetting the brush, etc)
• Remembering the brushing sequence within the mouth and reaching all teeth.
• Attention to brush for 2 minutes
• Remembering the sequence of the task after brushing (eg. spitting out the paste, washing the brush).

Tips to Help with Attention and Behaviour skills

• Use a kitchen timer, tooth brushing video or app to encourage 2 minutes of brushing.
• Use a reward chart if necessary.
• Use a checklist to mark off each aspect of the tooth brushing routine. 

                                                 Download your FREE checklist and reward chart here!

Additional Considerations

• Sore gums from teething
• Loose teeth
• Tooth decay and pain
• Dominant hand not established so brush is held with either hand

Tips to Help with these additional considerations

• Seek professional advice from a dentist about your child's tooth development and oral motor hygiene.
• Use baby teething gel such as  "Bonjela".
• Consider  bilateral coordination activities.  

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Do your kids like brushing their teeth? Have you downloaded your FREE tips sheet, checklist and reward chart? ​

This post is part of “Functional Skills for Kids: 12 month series by Paediatric Occupational and Physical Therapists”.  You can read all of the childhood functions HERE.  Read all Your Kids OT’s monthly posts HERE.

Find more information about “Personal Hygiene”, read what other Occupational and Physical Therapists participating in the “Functional Skills for Kids series” have written: ​

Task Analysis - Independent Bathing in Children  | Your Therapy Source
Tips and Tricks for Teaching Hand Washing with Kids  | Growing Hands-On Kids
I can brush my teeth! Tips for Tooth Brushing and Oral Care!  | Your Kids OT
Screen Free Quiet Time When Daytime Naps are History  | Kids Play Space
Tips to Help Kids Learn How to Blow Their Nose | Sugar Aunts
Tips to Help Kids Who Hate Haircuts | Mama OT
Sensory Friendly Tips for Kids Who Have Trouble Sleeping  |  The Inspired Treehouse
​Your Child With Special Needs: How to Conquer Showering Independently | Miss Jaime OT
Adolescent Hygiene Challenges  | Therapy Fun Zone

​Cindy is a registered Occupational Therapist practising in Sydney Australia.  She has two young children who are a constant source of inspiration and learning.  Cindy loves working creatively to help children to reach their potential, finding opportunities in everyday living and making learning fun. Cindy is the author of the occupational therapy blog Your Kids OT.

Disclosure: The information on this site is general in nature. The activities are safe for most children, however, 
​you should consult an Occupational Therapist or health professional to address specific movement, sensory or other medical conditions.  This article does not contain any affiliate links. 

​References:

• Bundy, A, Lane, S.J., Murray, E.A. (2002) Sensory Integration Theory and Practice (2nd Edition)
  
• ​Paediatric Occupational Therapy at Abertawe Bro Morgannwg University Health Board (2014) Oral Desensitisation. Retrieved on 20/09/2016 at  http://www.wales.nhs.uk/sitesplus/documents/863/Oral%20Desensitisation.pdf​