Mouths Matter - documents.hants.gov.uk · • A healthy mouth gives confidence and should be valued...

Mouths MatterImproving oral care for adults in care homes

Contents

l Introduction ............................................................................................... 3

l Knowledge ................................................................................................. 5• Why carry out oral care? ................................................................................................ 5

• Benefits to carers ............................................................................................................ 6

• Healthy mouth, teeth and gums ..................................................................................... 7

• Three steps to good oral health ...................................................................................... 8

• Oral diseases and conditions .......................................................................................... 9

• Tooth decay ..................................................................................................................10

• Gum disease ................................................................................................................12

• Tooth surface loss .........................................................................................................14

• Links to general health and systemic disease ................................................................15

• Oral hygiene methods ..................................................................................................16

• Dentures ......................................................................................................................19

• Advanced dentistry ......................................................................................................21

• The soft tissues .............................................................................................................23

• Soft tissue conditions ...................................................................................................24

• Dry mouth ....................................................................................................................27

• Oral cancer ...................................................................................................................28

• Alcohol misuse and oral health .....................................................................................29

• Smoking .......................................................................................................................30

l Practical skills ........................................................................................... 31• Assisting with mouth care ............................................................................................31

• Denture care ................................................................................................................33

• Denture marking ..........................................................................................................36

• Preventing denture loss ................................................................................................37

• Some ways to help when residents resist ......................................................................39

• People with dementia and denture wearing .................................................................41

• Dysphagia ....................................................................................................................43

• Palliative and end-of-life care ........................................................................................45

l Tools .......................................................................................................... 46• Oral health assessment .................................................................................................46

• Mouth care plan ...........................................................................................................47

• Daily documentation of oral care ..................................................................................48

• Appendix 1 ..................................................................................................................49

• Appendix 2 ..................................................................................................................51

• Appendix 3 ..................................................................................................................53

l Professional support ............................................................................... 55• How to find a dentist ...................................................................................................55

• Dental emergency and out-of-hours care .....................................................................55

• Special Care Dental Service...........................................................................................55

• Useful links ...................................................................................................................56

2 Mouths Matter handbook

3Mouths Matter handbook

Introduction

Welcome to Mouths Matter, a training initiative aimed at enabling care staff to provide a high standard of oral health care for adults living in residential and nursing homes.

This handbook compliments the facilitated training currently being provided by Hampshire County Council for new and existing staff working in care homes. To the best of our knowledge, all information is up to date and evidence based.

We recommend that in addition, healthcare staff are supported in accessing the programme, Improving Mouth Care, on the e-learning for Healthcare hub. This free resource by Health Education England Programme, in partnership with the NHS and Professional Bodies, introduces the basics of oral health care using a variety of images, videos and exercises.

www.e-lfh.org.uk/programmes/improving-mouth-care/

Mouths Matter is based on four key themes:

1. Knowledge of the importance of mouth care and good oral health and the links to general health and well-being.

2. Practical Skills gained through the training sessions on how to carry out oral health assessments and mouth care.

3. Tools needed to assist residents with good mouth care.

4. Professional Support for care staff and residents (and where appropriate their families) from dental professionals, oral health promotion teams and specialist dental services.

Further information

Improving oral health for adults in care homes: A quick guide for care home managers. www.nice.org.uk

NICE guideline [NG48] Oral health for adults in care home – July 2016. www.nice.org.uk

Care Quality Commission: Smiling matters: oral health care in care homes – June 2019. www.cqc.org.uk/publications/major-report/smiling-matters-oral-health-care-care-homes

Alzheimer’s Society – Dental care and dementia. www.alzheimers.org.uk/get-support/daily-living/dental-care

British Society for Disability and Oral Health. www.bsdh.org.uk

Stoke Association. www.stroke.org.uk/resources/dealing-swallowing-problems

http://www.nice.org.uk

http://www.nice.org.uk

http://www.cqc.org.uk/publications/major-report/smiling-matters-oral-health-care-care-homes


http://www.alzheimers.org.uk/get-support/daily-living/dental-care

http://www.bsdh.org.uk

http://www.stroke.org.uk/resources/dealing-swallowing-problems


Poor oral health can affect people’s ability to eat, speak and socialise normally.

People living in care homes are at greater risk of oral health problems for several reasons:

Long-term conditions (including arthritis, Parkinson’s disease and dementia) can make it harder to hold and use a toothbrush, and to go for dental treatment.

Many medicines reduce the amount of saliva produced and leave people with a dry mouth.

People now keep their natural teeth for longer, but this can mean they need more complex dental care than people who have dentures.

Thorough assessments, and support from skilled and knowledgeable staff can help prevent the pain, disturbed sleep and health problems that poor oral health can cause.

What the Care Quality Commission expectsThe Care Quality Commission expects registered managers to take account of nationally recognised guidance, including guidance from NICE.

Evidence about how you support residents to maintain good oral health will help you demonstrate that your service is both effective and responsive.

Oral health for adults in care homes NICE guideline (NG48)

NICE guidance is a set of evidenced-based recommendations for health and care in England. The guideline NG48 covers oral health, including dental health and daily mouth care for adults in care homes. The recommendations aim to help maintain and improve oral health and ensure timely access to dental treatment. A quick guide for care home managers can be downloaded here: www.nice.org.uk/improving-oral-health-for-adults-in-care-homes

The Care Quality Commission has carried out a review to find out how care home and dental providers were implementing this guideline. Their findings were published in June 2019 and can be viewed here: www.cqc.org.uk/publications/major-report/smiling-matters-oral-health-care-care-homes

© Care Quality Commission 2019

https://www.nice.org.uk/improving-oral-health-for-adults-in-care-homes




Knowledge

Why carry out oral care?

Good oral care is important for five reasons:

1. Overall health

Infections from the mouth can affect general health (and vice versa).

• People with diabetes are more prone to gum disease as reduced blood flow delays the healing process. Advanced gum disease may have an effect on blood glucose control, with any infection contributing to a rise in blood glucose levels

• Oral bacteria from a dental abscess or other oral infections may enter the bloodstream and cause more widespread infections

• Oral bacteria can also contribute to heart problems (endocarditis) if the resident has pre-existing heart valve problems

• Bacteria from the mouth can cause aspiration pneumonia in vulnerable residents.

All of these are potentially life-threatening for vulnerable dependant people.

2. Prevention of pain and suffering

• A painful mouth can be debilitating and upsetting

• Oral pain can affect mood and behaviour

3. Adequate nutrition

• A painful mouth can prevent a person from eating, drinking and enjoying their food

• Good oral health should also be linked in with malnutrition screening

4. Quality of life

• Poor oral health can lower self-esteem and alter self-image

• A healthy mouth gives confidence and should be valued

5. Communication, socialisation and appearance

• Poor oral health can affect the ability to speak and smile

• An unhealthy mouth can affect a person’s appearance, so a healthy mouth can encourage confidence

Key message:Oral care like bathing, toileting and feeding is essential to the holistic care provided to residents. Oral care should receive the same priority as other personal care and should be an integral and routine part of care for all residents.


• good oral care can help prevent dental disease

• a painful mouth can lead to behavioural problems

• a healthy mouth may encourage the service user to be more cooperative

• service users should have fewer problems eating

• bad breath should reduce, creating a more pleasant atmosphere.

Benefits for carers

It is important that oral care is documented – this means carers will have protected themselves (legally)

if there is a claim of negligence.


Dry mouth

Denture problemsThrush

UlcersTooth decay

Undiagnosed redand white patches

Bleeding andswollen gums

Unhealthymouth

No broken �llings/dentures

Mouth that is moistwith saliva

No decay (holes) in the teeth

Denturesare clean and

�t well

The mouthis clean

No mouth ulcers or undiagnosed red or

white patches

The gums, tongue and cheeks are healthy

and pink

Healthymouth

Knowledge

Healthy mouth, teeth and gums

A healthy mouth should be achievable for all adults living in residential care or supported living. Mouth care is therefore an essential part of personal care, without which, oral health will deteriorate.

What is an unhealthy mouth?

Remember! Whenever possible, a person should be encouraged to carry out their own mouth care. However, some

individuals may find this difficult and may need support.


Three steps to good oral health

Three steps to keeping the mouth healthy

1 Brush teeth thoroughly twice a day with a fluoride toothpaste containing at least 1350 parts per million (ppm) fluoride. For most people, ‘spit don’t rinse’ is advised.

2 Keep sugary snacks and drinks to mealtimes where possible.

3 Visit the dentist regularly for dental check-ups. Even if someone has no natural teeth, they should still see a dentist at least every two years to check that their mouth is healthy.

Toothbrushing, diet and dental visits are the main steps towards good oral health but may need some adaptations.

Possible adaptations for adults with additional needs

1. ‘Spit, don’t rinse’ may not be possible for everyone, for example dry mouth, stroke, Parkinson’s disease. Use a non-foaming toothpaste (without sodium lauryl sulphate).

2. Those who require specialist dietary support, eg. under nutrition or dehydration, seek professional advice OR where effective mouth care is not possible, ‘Think! Low sugar diet’.

3. Access to a dentist may vary between homes, especially where domiciliary care is needed. Those individuals requiring specialist dental care can be referred to the Special Care Dental Service (details are provided at the back of this book). Please be aware that residents will be liable to pay patient charges towards the cost of any NHS dental treatment, unless they have a current exemption.

If in doubt, always seek advice from a dental professional.


Knowledge

Oral diseases and conditions

Remember! Dental decay and gum disease are entirely preventable

The most common oral diseases are tooth decay and gum disease. These are both caused by plaque.

What is plaque?• It is the sticky film of bacteria that forms

minutes after brushing.

• It can form on all surfaces of the teeth, dentures, crowns and bridges.

• It contributes to tooth decay and is the major cause of gum disease.

• It is present in everyone’s mouth.

• If it is left in the mouth it will harden and became calculus (scale or tartar).

How do you remove it?• By thorough toothbrushing, at least twice daily.

• Once formed, calculus can only be removed by a dental professional.

Plaque irritating the gum Tooth decay

Additional information:

• Plaque and calculus can form above and below the gum.

• Any crooked teeth, overhanging edges on filings, partial dentures will all encourage the build-up of plaque.

• Plaque still forms in the mouths of people who are: Nil by mouth; parenteral feeding; oxygen therapy.

Dental plaque


Tooth decay

What is tooth decay?

• It is destruction of the enamel and dentine of the tooth.

• When the enamel is weakened it can break and form a hole in the tooth (cavity).

• When the decay reaches the dentine it can cause pain and infection.

What causes tooth decay?

• Frequent consumption of sugary foods and drinks.

• Whenever sugars from foods and drinks are mixed with the plaque bacteria, acid is formed.

• This acid causes the tooth enamel to start to soften and dissolve (demineralisation) and is also known as an ‘acid attack’.

• The attacks can last up to two hours after eating or drinking, before the natural salts in your saliva cause the enamel to ‘remineralise’ and harden again.

• If more sugar containing foods or drinks are taken within this time the acid attack will last longer.

• The more acid attacks that take place, the higher the risk of tooth decay.

• Dental erosion is the wearing away of enamel caused by acids in some foods but mostly soft drinks, even diet versions!

Sugar alert!Always check the ingredients. Generally anything with ‘ose’ in the name

is a sugar, for example: sucrose, maltose, dextrose.

Advice on nutritional supplements or smoothies should be sought from a dietician and the person’s dentist. Ideally, they should be drunk within a short space of time and if possible through a straw.

Having sugary or acidic snacks and drinks between meals can increase the risk of decay, because your teeth come under constant attack and

do not have time to recover. It is therefore important not to keep having sugary snacks or sipping sugary drinks throughout the day.

Tooth decay


Knowledge

The only safe drinks to have between meals are:

• plain milk

• plain water

• tea or coffee with no sugar (artificial sweeteners are acceptable).

Sugar free alternatives can be offered and try to keep sugary drinks to mealtimes only.

Safe snacks to have in between meals are:

• fresh fruit

• fresh vegetables

• toast and butter

• crumpets and butter

• savoury sandwiches

• crackers and cheese.


Gum disease

What is gum disease?

There are two types of gum disease:

• Gingivitis

• Periodontitis (the most common cause of tooth loss)

Gingivitis

• The early stage of gum disease which can be reversed.

• Gums around the teeth become red, swollen and bleed when brushed.

• First signs can be blood on the tooth brush or after spitting out.

• Gums often bleed because they have been inflamed by plaque, not because they have been brushed too hard or pricked by the bristles.

Periodontitis

• Advanced stage of gum disease that has affected the supporting tissues of the teeth (gum and bone) which have been destroyed by the plaque underneath the gum, making the teeth loose.

• Teeth can be lost through gum disease

• Loose teeth can cause problems as they affect a person’s ability to eat and speak as well as impacting on their quality of life.

• Loose teeth may fall out and be inhaled or ingested, leading to a possible medical emergency.

• Often accompanied by bad breath (halitosis).


Knowledge

How is gum disease prevented?

• Thorough and effective removal of dental plaque by regular and methodical toothbrushing, ideally twice daily.


• Seek advice from a dental professional about effective oral hygiene aids

• Mouthwashes should be used under the direction of either a medical or dental professional and ideally be alcohol free.

• Gums of smokers can mask more serious periodontal problems

Gingivitis Periodontitis

What causes gum disease?

• Plaque and poor oral hygiene.

• Smoking can also make the disease worse as it causes a lack of oxygen in the bloodstream which makes healing more difficult.

Plaque can only be removed from teeth with a toothbrush. Foam swabs and Moutheze cleaners do not remove plaque and should not be used instead of a toothbrush.


What is tooth surface loss?

Tooth surface loss or tooth wear are the terms used to describe the gradual loss of the tooth’s surface due to actions other than those which cause dental decay or trauma. Tooth wear increases as we get older.

What are the causes?

• Erosion is caused by the frequent or prolonged exposure to acid. The acid can be from food and drink (extrinsic) or gastric acid as a result of acid reflux or frequent vomiting (intrinsic). Those with low saliva flow or dry mouth are at a higher risk.

• Attrition is the wearing away of tooth surface as a result of tooth to tooth contact by mastication or grinding between opposing teeth. The extent of attrition varies from some loss of the enamel, exposing the dentine or in extreme cases, the wearing away of the tooth to gum level. Those with learning disabilities or mental health issues are more prone to attrition.

Some people habitually clench or grind their teeth (a condition known as bruxism), e.g., during sleep. Other factors include stress, a lack of teeth causing additional force on remaining teeth; and the regular use of chewing gum or tobacco.

• Abrasion is the loss of tooth surface by mechanical force and is most commonly associated with incorrect tooth brushing technique. The long-term use of tongue jewellery also causes tooth abrasion, when the jewellery is hitting against the teeth.

Tooth surface loss

Some examples of acidic foods and drinks include citrus fruit, fruit teas, fruit juices, fizzy drinks, squash, alcohol and vinegar.

Symptoms of tooth surface loss can range from sensitivity to hot and cold, extreme pain and no symptoms at all.

Management

Service users should be supported in seeing their dentist regularly for monitoring and any recommendations written into their mouth care plan. If possible avoid giving soft drinks containing sugar and/or acid to those with a dry mouth as it can increase the level of acid attack on the teeth. If a person is suffering from acid reflux or vomiting, avoid tooth brushing for 30 minutes.

Attrition


Tools

Links to general health and systemic disease

There is increasing evidence to show that poor oral health and poor oral hygiene are linked to general health and chronic systemic disease.

For those residents with pre-existing medical conditions, poor oral health could be life threatening.

+–

heart diseaseheart disease

strokes

lung conditions

dental decay

bad breath

mouth cancer

diabetes

gum disease

tooth loss

What problems could poor dental health cause?


Oral hygiene methods

Natural teeth

If teeth are not cleaned regularly and thoroughly, decay can occur and lead to tooth infections and pain. Good oral hygiene is essential to help avoid tooth decay and gum disease.

When do you need to help with toothbrushing?

• Residents who are able to brush their own teeth should be encouraged to do so morning and night.

• Existing methods of brushing may need to be modified to ensure maximum plaque removal.

• If support is needed, it may be helpful to do this by reminder, verbal encouragement or hand over hand technique.

• Residents with medical conditions such as stroke, arthritis, Parkinson’s disease and dementia are likely to need help to brush their teeth.

• Some residents may benefit from the toothbrush handle being adapted or use a special toothbrush.

What type of toothbrush?

• A small headed medium textured toothbrush is suitable for most people.

• Toothbrushes should be replaced every three months or when the bristles are splayed.

• Toothbrush handles may be adapted to improve the grip for some people.

• Residents with limited dexterity should have a large handle that provides a firm comfortable grip.

• Consider a special toothbrush such as the Collis Curve or Superbrush where toothbrushing is difficult.

• Electric toothbrushes are helpful for residents who suffer from arthritis or cannot grip a manual brush.

What type of toothpaste?

• Using a pea size amount of toothpaste with at least 1350 ppm (parts per million) fluoride twice daily increases the tooth’s defence against decay.

• This information can be found under the ingredients list on the tube or box.

• Toothpastes which contain higher levels of fluoride (2800ppm or 5000ppm) is sometimes prescribed by a dentist where a person is at a higher risk of developing tooth decay and should be used as directed.


Knowledge

Additional information:• Residents with a dry mouth or ulceration may find a silk toothbrush

more comfortable.• Finger brushes can be used for massaging the gums.• Electric toothbrushes with a rotating and oscillating action reduce

plaque and gingivitis more than a manual toothbrush.• The heads on electric toothbrushes wear out the same as manual

brushes and need to be replaced regularly.

Toothbrushing techniques

• Effective brushing must include the gum edges as this is where most of the plaque collects.

• Small circular brush strokes are most effective.

• Remember the teeth have three surfaces – outside, inside and chewing surfaces.

• Top and bottom teeth should be brushed separately.

• Effective toothbrushing should take about 2 minutes.

• Spit, don’t rinse!

• If tolerated, gently clean the tongue

Superbrush

Adapted brushes Collis Curve brush



• Can be diluted 50/50 with water

• Effective in the treatment of gum disease

• Should be used in the short term

Chlorhexidine (Corsodyl)

• Works by reducing the amount of plaque that forms on the teeth

• Can come in different forms e.g. gel, spray and mouthwash and is available from pharmacies or on prescription from the doctor or dentist

• Should be used at at a different time to fluoride toothpaste for both to work well

• Should only be used for short periods of up to a month. Teeth can become stained if long term use is adopted

• Use as directed by your dental professional, if in doubt always seek professional advice

Experiences of care – good oral care adapts to a person’s needs

Ann had different experiences of oral care at the three care homes she lived in.

She was admitted for emergency respite care to the first home. She had four lower teeth of her own plus upper and lower dentures. Ann’s daughter noticed that both her toothbrush and denture brush were dry and that her toothpaste had not been opened, so she helped her clean her teeth and dentures.

Ann moved into long-term residential care, where she had a good supply of dental products which staff bought using money from her petty cash account. Care staff encouraged and supported her to clean her teeth and dentures and complimented her for her “sparkly teeth and lovely smile”. Ann beamed with pride when this was said and it was reassuring for her daughter to see her looking so cheerful.

When Ann’s Alzheimer’s became advanced, she moved to a specialist dementia care home. She enjoyed having her hair brushed and her teeth gently cleaned by cheerful and patient care staff. Her daughter could see from her mum’s smile and the twinkle in her eyes that she was happy. The home posted on their Facebook page (with permission) photos of Ann at events like the Halloween Disco. It was very reassuring for her extended family to see her enjoying herself and smiling.

Note: We have changed people’s names.


Knowledge

Encourage residents to remove their own dentures. If they have difficulty, remove dentures by sliding a gloved finger by the side of the denture to help break the seal between the mouth and the denture.

Denture fixative is often used to help increase the retention and comfort of dentures. Fixative will need to be removed from both the denture and the resident’s mouth using a denture brush and toothbrush respectively.

Guidelines on the use of denture fixatives can be found here:

www.dentalhealth.org/dentureadhesives

Remove at night, cleaned and stored in fresh water in a denture pot clearly labelled with the person’s name.

A resident may wear a full or partial denture, made of acrylic or acrylic and metal.

• Full dentures replace all the teeth in one arch as there are no natural teeth

• A partial denture replaces a few missing teeth and fits around the remaining natural teeth

• It can be difficult to tell what are natural teeth and what are dentures

• Dentures should be marked with the residents name

• Denture hygiene is just as important as oral hygiene for natural teeth

• Some residents can be very reluctant to remove their dentures

• Ideally dentures should ideally be removed, cleaned thoroughly and left out overnight. This is to allow the gums and mucosa (soft tissues in the mouth) to rest and helps to prevent fungal infections.

Dentures

http://www.dentalhealth.org/dentureadhesives


Denture care

• Denture care is very important. Dentures are expensive and may be difficult to replace for some residents

• Dentures should ideally be marked with the residents name

• Plaque grows on all surfaces of the denture and should be removed thoroughly every day

• Dentures should be cleaned morning and night using a toothbrush, denture brush or nailbrush and unperfumed soap and water or denture cream

• The residents palate, gum ridges and tongue should be cleaned with a soft toothbrush

• Where possible, dentures should be rinsed after every meal.

• Dentures should be left out of the mouth for a minimum of four hours a day but preferably overnight. This allows the gums and mucosa (soft tissues) to rest and help prevent fungal infections such as denture stomatitis and oral thrush

• When dentures are not in the mouth they should be stored in a labelled pot in plain water

• A denture soaking solution may be used after they are thoroughly cleaned, for 20-30 minutes only. The denture should then be rinsed and stored in plain water.

Remember!

If a resident has a partial denture and some natural teeth then both the denture and teeth need to be cleaned.

It is recommended that a risk assessment is carried out and that denture soaking is supervised.


Knowledge

We are a changing population and our mouths are changing too

We are an ageing population and as we are living longer, so we are retaining our teeth for longer. People are also able to access a wide range of restorative and cosmetic dentistry all of which need additional care to maintain and keep healthy. By ensuring that this is noted in a person’s oral health assessment, the appropriate level of support can be given if their ability to care for their mouth changes.

Dental implants

Dental implants are artificial roots directly implanted into the gum and bone to hold crowns, bridges or dentures, replacing missing or damaged teeth. Each implant is essentially a metal screw made of titanium. Titanium is “biocompatible”, meaning it is not rejected by the body and the metal will fuse with the surrounding living bone.

Advanced dentistry

Some residents may have a denture/s which are held in place via implants that are placed in the jaw bone. These implants will need to be cleaned in the same way that teeth are cleaned and the dentures removed and cleaned in the same way as other dentures.

Dental crowns and bridges

Both crowns and bridges are fixed into place. Unlike removable devices such as dentures, which you can take out and clean daily, crowns and bridges are cemented onto existing teeth or implants, and can only be removed by a dentist.

A crown is used to cover or “cap” a damaged tooth but can also be placed on top of an implant to provide a tooth-like shape and structure for function. Crowns are matched to the colour of a person’s natural teeth so may be difficult to spot.

A bridge is commonly used to replace one or more missing teeth. They span the space where the teeth are missing and are cemented to the natural teeth or implants surrounding the empty space.

While crowns and bridges can last a lifetime, they may come loose or fall out. If this occurs, place the crown or bridge in a safe place and contact the resident’s dentist. If no further damage has occurred, the dentist should be able to re-cement it.

Veneers

A veneer is a new ‘tooth’ surface which fits over the front of a tooth. It is made of porcelain and matches the colour of the surrounding teeth.


Experiences of care – personalised care of someone with complex needs

Joshua is 23. He has a severe learning disability, has communication difficulties, and can display behaviour that can be challenging. He lives in a care home in the community, which is near to his healthcare professionals.

Staff support Joshua to clean his teeth twice a day after breakfast and before bed. They help by cleaning his teeth when he is in the bath or when he is sitting at the table, which he seems to prefer. Staff try to make it fun.

Since Joshua has sensory issues, he would really suffer if he experienced dental pain – especially since he would be unable to show where the pain was. He could also harm himself or others. His quality of life is improved by avoiding intrusive dental work, which would cause him much anxiety and most likely require a general anaesthetic. Since he

suffers with epilepsy a general anaesthetic could be dangerous for him.

Joshua’s oral health needs are included in his care plan, which his mother was involved in to help make sure it met his needs. For example, she explained that cleaning his teeth in the bath and singing a song with him would help him feel more at ease.

His mother says, “I am confident that Joshua is treated with dignity and respect. Staff are caring and kind and keep me updated. I feel that Joshua is involved in his teeth cleaning routine – it is not ‘forced’ upon him. I have thanked the staff for the support they give him and I feel that they are pleased that their efforts are acknowledged.”


In all cases, a resident should avoid biting into and/or chewing hard sticky foods and, importantly, maintain good oral hygiene.


Knowledge

Tongue

What is a healthy tongue?

• Pink and symmetrical, with a slightly rough surface

• The roughened upper surface is covered with tiny papillae

• At the back of the tongue are large specialised papillae which look like big lumps

• Like any surface in the mouth, the tongue should be kept clean and moist

• When a person has a dry mouth the tongue surface can become sore and cracked and require a specialised cleaning regime. There are a lot of contributing factors to dry mouth and it is a common side effect of many medications

• Conditions such as black hairy tongue are harmless, but need to be kept clean.

The soft tissues


• When a person has a dry mouth it can look dry and become fissured with the surface becoming sore and coated. This will need a specialised cleaning regime.

• It is always best to seek advice from a dental professional.

Geographic tongue Dry tongue Black hairy tongue

Looking after oral soft tissues is just as important as looking after teeth!


Infections

• Fungal infections in the mouth are common with older people who wear dentures. These infections can show as an area of redness under an upper denture (denture stomatitis) or as generalised redness or white patches (oral thrush).

• The corners of the mouth can also appear cracked, red or crusting (angular cheilitis). Fungal and bacterial infections can contribute to this condition.

Soft tissue conditions

Angular cheilitis

Bacterial infections of the lining of the mouth can cause generalised redness. The bacteria can also

cause serious respiratory tract infections such as pneumonia.

Prevention: Good oral care and denture hygiene helps

to prevent or reduce oral infections. Inadequate dental care can lead to the following conditions:


Knowledge

The lining of the mouth also needs to be cleaned.

• For cleaning the soft tissues, use damp non-fraying gauze (use clean running water to make this wet) wrapped around a gloved hand.

• The gauze should be changed as required and several pieces may be needed to clean the whole mouth.

Sponge sticks

• They don’t remove plaque from the tooth surface. If used, they are for moistening or cleaning the soft tissues only and should be discarded after one use.

The foam sponge may come off the stick and be aspirated! This seems to happen when the stick has been allowed to soak.

Lips

• Dry cracked lips are uncomfortable.

• To clean, moisten non-fraying gauze and gently wipe the lips. A water-based saliva replacement gel or aqueous cream can then be applied.

• Petroleum lip balms are not recommended for residents receiving oxygen therapy due to flammability and aspiration risk.

Excessive salivation or drooling

People with swallowing difficulties, eg. dysphagia together with poor lip closure and poor control of the head causes saliva to accumulate in the mouth. This can lead to drooling, especially if the head position is down. It is rarely due to the person producing excess saliva.


Mouth Ulcers

Mouth ulcers are common and should clear up on their own within a week or two. The following advice will help residents to avoid things which can irritate mouth ulcers, reduce pain and speed up the healing process.

A dentist or doctor should check your resident’s mouth ulcer if it:

• lasts longer than 3 weeks

• keeps coming back

• becomes more painful and red – this may be a sign of an infection.

Do

use a soft-bristled toothbrush

drink cool drinks through a straw

eat softer foods

get regular dental check-ups

eat a healthy, balanced diet

Don’t

eat very spicy, salty or acidic food

eat rough, crunchy food, such as toast or crisps

drink very hot or acidic drinks, such as fruit juice

use chewing gum

use toothpaste containing sodium lauryl sulphate

Although most mouth ulcers are harmless, a long-lasting mouth ulcer is sometimes a sign

of mouth cancer. It’s best to get it checked.

Mouth ulcer


Knowledge

Dry Mouth

The importance of saliva

• Saliva protects and lubricates the teeth, gums and all soft tissues in the mouth.

• A lack of saliva causes dry mouth (xerostomia), which can result in difficulties with speaking, swallowing and eating and is common in adult and older people living in care homes.

• A dry mouth can go undetected, especially in people with dementia. It can also be caused by underlying problems or medical conditions such as a blocked nose, diabetes, radiotherapy to the head or neck and Sjogren’s syndrome.

• It is a very common side effect of many medications including antidepressants, antihistamines and diuretics.

• A dry mouth is an important risk factor for tooth decay in residents who have their own natural teeth.

• It can make wearing dentures difficult.

It’s important to maintain good oral hygiene if someone has a dry mouth. This helps reduce the risk of dental problems.

Residents should see a dentist regularly so that they can identify and treat any problems early on.

How can you help a resident with a dry mouth?

• Encourage regular sips of water (if the resident has swallowing difficulties, advice must be sought from your local Speech and Language Therapy team).

• Saliva substitutes, for example water-based saliva replacement gels and sprays, are widely available either on prescription or over the counter.

• Strict control of sugary foods and drinks is essential to prevent tooth decay. The use of high-fluoride toothpaste, may be prescribed by a dentist.

• Fluoride mouthwashes may also be prescribed.

• Avoid any dry food as this will be difficult to swallow.

• Check daily for oral thrush.


What is oral cancer?

• Oral cancer can affect the lips, mouth or throat.

• Most head and neck cancers occur in the larynx.

• Oral cancer is twice as common among males as females.

• Approximately 85% of new cases occur in people aged over 50 years.

• Head and neck cancer in England is more common in people living in the most deprived areas.

What to look for:

• Any red, white or speckled patches.

• Ulcers or sores that do not heal within two weeks. Any ulcer present for two weeks or more – even if painless – must be investigated by a dentist urgently.

• Lumps or bumps in the mouth or on the lip.

• Unexplained speech patterns or difficulty in swallowing.

Risk factors:

• People who smoke and drink alcohol heavily are at higher risk.

• Cancers found on the lips are frequently associated with excessive exposure to the sun, for example building workers, gardeners and farmers.

Early detection of mouth cancer is important, so ‘if in doubt, check it out’.

Oral cancer

Cases SurvivalDeaths Prevention

New cases of head and neck cancer,

2015, UK

Survive head and neck cancers for 10 more years, 2009-15, UK

Deaths from oral cancer, 2014, UK

Preventable cases of head and neck

cancers, UK

12,061 2,386 19%-59% 91-93%

Further information:

www.cancerresearchuk.org/about-cancer/mouth-cancer

www.nhs.uk/conditions/mouth-cancer

http://www.cancerresearchuk.org/about-cancer/mouth-cancer

http://www.nhs.uk/conditions/mouth-cancer


Knowledge

Drinking alcohol to excess is linked with mouth cancer and the risk greatly increases for those who drink and smoke.

It is very important that you visit the dentist regularly for an oral health check.

Find out more at: www.mouthcancer.org

www.drinkaware.co.uk

Alcohol misuse is a significant problem in England with over a million admissions to hospital every year for alcohol-related harm. This section will highlight the extent of the problem and summarise the links between alcohol and oral health.

Impact of alcohol misuse on oral health

Drinking above the lower risk guidelines adversely affects oral health in a range of ways. The most important effect is undoubtedly the significantly increased risk of oral cancers among drinkers.

• The incidence of oral cancer has steadily increased since the 1970s.

• The most important risk factors for oral cancers are the combined effect of tobacco use and consumption of alcohol.

• It is estimated that heavy drinkers and smokers are 38 times more likely of developing oral cancer than those people who abstain from both products.

• Excessive alcohol consumption is also associated with dental trauma and facial injury either through accidental falls, road traffic accidents or violence, both domestic and street related.

• Drinking above lower risk levels is also associated with tooth surface loss due to erosion caused by the acidity of drinks such as alcopops, cider and wine (Robb and Smith, 1990).

Alcohol misuse and oral health


Every cigarette you smoke is harmful.

Smoking is the biggest cause of preventable deaths in England, accounting for nearly 80,000 deaths each year.

One in two smokers will die from a smoking-related disease.

Smoking causes unattractive problems such as bad breath and stained teeth, and can also cause gum disease and damage to the sense of taste.

The most serious damage smoking causes in the mouth and throat is an increased risk of cancer in the lips, tongue, throat, voice box and gullet (oesophagus). More than 93% of oropharyngeal cancers (cancer in part of the throat) are caused by smoking.

The good news is that when a person stops using tobacco, even after many years of use, it can greatly reduce the risk of developing head and neck cancer. Being smokefree for 20 years means that your risk of developing head and neck cancer is that of a non smoker.

Read more at www.nhs.uk/smokefree/why-quit/smoking-health-problems

Smoking

Smoker’s mouth


Practical skills

Assisting with mouth care

Assisting a resident to maintain the health of their natural teeth will almost certainly become a more common task for care staff, as many people are keeping their natural teeth far longer. If a resident is admitted into care with some or all of their own teeth this means that they have taken great care of their own oral health. Residents have the right to expect this to continue even if they become unable to look after their own teeth. Oral care should be carried out as an integral part of personal care.

You may feel nervous about brushing someone else’s teeth in case you hurt them or feel reluctant to persist

in helping a resident who resists or is uncooperative.

It is becoming more evident that neglecting to provide an adequate level of oral care can lead to serious, debilitating and even life threatening conditions. Therefore being appropriately trained in the practical skills to carry out oral care is essential.

Few of us have been taught how

to clean our teeth properly and it

is a skill that needs to be learned

and practiced daily. It is even

more difficult to clean someone

else’s teeth! You can’t learn this

skill from reading about it, try

practicing on a friend or family

member. Remember to swap

roles too so you can experience

this for yourself.

Observe and Report

By regularly checking a residents’ mouth you will be able to note any changes or problems and report to the person in charge who will record the detail within the residents’ personal plan. Appropriate steps can then be taken to have the resident seen by a dentist.

Some residents may need a simple reminder to brush their teeth or clean their dentures daily, others may require more assistance or be fully dependent on staff for all mouth care.

Pen torches

It is impossible to fully assess the mouth without a light source. Many conditions, especially the back of the mouth, will be missed.


Steps for brushing natural teeth

1. Where possible, the resident should be seated and in a chair where you can stand behind them and rest their head in the crook of arm. You may need to try different positions to suit the individual needs of the resident but make sure that their head is supported.

2. On a dry brush, place a pea sized amount of fluoride toothpaste.

3. Start either on the upper or lower jaw. Brush around the outside of the teeth first, gently scrubbing each tooth for a count of six.

4. When you finish the outside work your way back on the inside, methodically cleaning each tooth.

5. Then clean the biting surface of the teeth.

6. Start again on the other jaw, repeating each stage.

7. If the gums bleed , this is usually the result of the build-up of plaque, continue to brush them gently as this is the only way to remove the plaque from the teeth.

8. Allow the resident to spit out, assisting only when required.

9. Rinse the brush after use and store in an upright position and allow to air dry.

For residents who require assistance

Prompt – Encourage – Support


Practical skills

Suggested equipment:

• Disposable gloves and apron

• Named denture lidded pot

• Toothbrush or denture brush

• Denture cream or unperfumed soap (not regular toothpaste)

• Sink filled with water

• Resident’s own clean towel

Denture care

When helping a resident with their oral care, remember to:

Prompt – Encourage – Support

Important! Denture soaking solution is not an essential part of mouth care and should only be used if advised by a healthcare professional

and combined with a thorough risk assessment..

• Denture care is very important. Dentures are expensive and may be difficult to replace for some residents.

• Dentures should be marked with resident’s name.

• Plaque grows on the surfaces of dentures and should be removed thoroughly every day.

• The most effective way to remove plaque from dentures is by thorough brushing using a toothbrush, denture brush or nail brush and unperfumed soap or denture cream. Rinse well with cold water.

• Where possible dentures should be rinsed after every meal.

• Dentures should be left out of the mouth for a minimum of four hours a day, preferably overnight, to allow the gums and mucosa to rest and to help prevent fungal infections

• When dentures are not in the mouth they should be stored in a named pot in plain water.

• A denture soaking solution may be used, after thorough brushing, for 20-30 minutes. The denture should then be rinsed and stored in plain water.

• If a resident has a partial denture plus natural teeth, both the denture and the teeth need to be cleaned.


Steps for removing full dentures

1. Check if the resident can remove their own denture.

2. Before removing, if possible ask the resident to take a sip of water.

3. If a resident needs help with removing their denture, wash hands and put on gloves.

4. If the resident is unable to remove their dentures, remove the lower one first.

5. To remove the upper denture, slip finger by the side of the denture to break the seal and lift the denture out of the mouth at an angle.

Remember! Someone’s ability to remove/replace their dentures

may change from day to day.

Removing partial dentures:

Some partial dentures can be difficult to remove.

• If the resident is able, ask them to remove the partial denture.

• If not, carefully place your fingers under the clasps that are hooked on to the teeth and gently push downwards.

• Take hold of the plastic part and pull carefully out of the resident’s mouth. Avoid bending the wire.

Key message:If possible, seek advice from a dental professional, especially if caring for partial dentures is new to staff.


Practical skills

Inserting full dentures:

• Dentures should be rinsed under clean water before being replaced in the resident’s mouth.

• If the resident is able to do this themselves, then encourage independence: if not, replace upper denture first.

• Replace each set by gently inserting the denture at an angle then rotate into position.

Inserting partial dentures:

• If the resident is able, encourage them to replace the denture.

• If not, after rinsing the denture in water, ask the resident to open their mouth, insert the denture at an angle and rotate and click into position.

Denture removal mp4 video: www.youtube.com/watch?v=ilLxOU-tGYI

Experiences of care – good oral care adapts to a person’s needs

Nancy is 81 and lives with dementia. She lives in a nursing home where she is fully supported with her personal needs.

When she started living at the home, she had all her own teeth, which were in good condition. She had always taken considerable care of her oral health and was very proud to have reached her age without the need for dentures.

This was recorded in her care plan, and care staff were directed to ensure her teeth were cleaned twice a day. Initially, staff were asked to remind Nancy to clean her own teeth, and to ensure she managed this for herself.

As her capacity and ability to take care of her own oral health has declined, staff have increased their role in keeping her teeth clean.

Nancy’s son said, “It has been very difficult for our family to witness dementia take our mother’s independence, memory and dignity. Positively, however, it has not taken her teeth, and given how important we know this is to her, we thank the staff at her nursing home for their help in securing this outcome.”


https://www.youtube.com/watch?v=ilLxOU-tGYI


Suggested equipment:

• Disposable gloves and apron.

• Antibacterial wipes.

• Denture cream or unperfumed soap.

• Denture marking kit, which includes:

• Sandpaper squares (single use)

• Metal propelling pencil (which must be cleaned after use with antibacterial wipe)

• Approved sealant

• Disposable micro-brush or similar (single use).

Denture marking

If using a commercial kit, please follow the manufacturer’s instructions. This form of denture marking is not permanent.

Using effervescent cleaners may increase the need to remark the dentures. Check the marking when carrying out oral health risk assessment

reviews and remark if necessary.

Residents are prone to losing their dentures, so denture marking is important as it provides easy recognition of the resident’s denture/s. It can be difficult to adapt to new dentures and they are also very costly to replace.

Ideally, dentures are marked with the resident’s name when they are being made. This may not be the case, especially with older dentures. If dentures do not have any identification, they should be marked with the resident’s name or initials.


Practical skills

The denture sunflower

To try and reduce the number of lost dentures you can adopt this simple method. Ask the resident if a sunflower sign can be placed in their

room. This symbol will act as a visual aid for staff to check for dentures wrapped in tissue or hidden in bed linen to reduce the risk of them being accidentally lost. It will also remind staff that a resident has dentures that

require cleaning and storing in a labelled denture pot overnight.


Practical skills

Do all you can to encourage as much independence as possible. Residents may exhibit less resistance when care staff encourage them to carry out their own oral care. The following are simple techniques and strategies to keep in mind when assisting people who resist:

Time and place

• Develop a routine with oral care. Carrying this out at the same time every day may help. People with dementia can have patterns so consider asking family members or previous carers for advice or assistance.

• Sometimes it may be helpful to have more than one care assistant helping, but the person may also respond better to one well-known member of staff.

• Carry out the task in a quiet distraction-free environment with sufficient light, and where the resident is most comfortable. The location should be as private as possible to preserve the dignity of the resident.

Some ways to help when residents resist

Communication strategies

• Be caring, calm and friendly, and smile.

• Talk clearly, at the resident’s pace.

• Explain in short sentences and in simple terms what you are doing.

• Try only to ask questions that require a yes or no answer.

• Use reassuring and appropriate body contact and gentle touch.

• Remain positive and try to refrain from showing any frustration.

Behaviour strategies

• Be aware of the resident’s needs.

• Position – don’t approach the resident from behind. Rather, come down to eye level. Be aware of individual need for personal space.

• Ensure the resident is relaxed and be willing to slow down or try later.

• Use task breakdown – simplify and break down the steps of any activity and don’t expect a person with dementia to remember more than one step at a time. Offer praise for completion of each step if appropriate.


If the resident shows reluctance, try using these helpful strategies:

• Bridging – this helps to engage a resident with the task through their senses and helps them to understand the task. Describe and show the toothbrush to the resident, mimic brushing your own teeth, give a spare toothbrush to the resident, and the resident may mirror your behaviour and brush their own teeth.

• Chaining – this involves gently bringing the resident’s hand to the mouth while describing the activity. Let the resident continue if they are able.

• Hand over hand – if chaining is not successful, then place your hand over the resident’s and gently brush the teeth together.

• Distraction – if none of these strategies work, then try distracting the resident by placing a familiar item in the resident’s hand while you brush the resident’s teeth.

• Rescuing – this is a common tactic used with other hygiene tasks. If attempts are not going well, the care assistant can leave and the ‘rescuer’ comes in to take over. Bringing in someone else with a fresh approach may encourage the resident to cooperate. If none of the suggested techniques work, then it might be helpful to review your approach:

• Think again about your attitude and body language – showing any frustration will be counter-productive.

• Is the location comfortable and familiar for the resident?

• Is it the best time of day for the resident?

• Do you need to ask others for help?

• If all attempts fail, do not just give up!

• Consider alerting the resident’s family if this has not been done previously (unless the resident’s medical practitioner has assessed the person as having capacity to consent – in this case the resident should agree prior to family members being informed).


Practical skills

People with dementia and denture wearing

There may come a time when it is in the best interests of a resident to stop using their dentures. This may be because the resident can no longer tolerate them or the dentures no longer fit. Badly fitting dentures make eating difficult which increases the risk of under-nutrition.

A dentist can reline badly fitting dentures and will do this if they feel it is appropriate, but this may only provide a temporary solution. Some people will be able to tolerate the process of having new dentures made, but it can be very distressing for others. In some cases a dentist can make a copy of a resident’s dentures using their current set and this may result in a resident adapting to new

dentures more easily. In this case, care should be taken to ensure the existing dentures are not disposed of.

As people get older it can be difficult to make dentures that fit well. Adjusting to new dentures can also be very difficult for some older people, particularly those with dementia.

It can be upsetting for some family members to see their relative without their dentures and they may ask that they continue to be worn. However, the best interests of the resident must always prevail. This issue may need to be handled sensitively, and the outcome should be always be in line with the dentist’s or doctor’s instructions.

Seek advice from a dental professional

The Alzheimer’s Society has produced a comprehensive fact sheet on Dental Care and Oral Health and describes types of dental treatment and planning for the early, middle and later stages of dementia (see page 3).


Experiences of care – when oral care is not a priority, it can have a very

negative effect on people’s dignity

Lucy had Alzheimer’s and died aged 89 having spent 18 months in a care home.

Throughout this period, staff needed to help Lucy take care of her teeth and dentures by encouraging her to brush her teeth regularly and by cleaning her dentures for her daily.

However, over time her family had to repeatedly encourage the staff to help her to maintain good oral health and to look after her dentures, which were lost on two occasions.

Generally, Lucy would not be wearing her dentures when a family member visited her. They would still be in her bedroom because the night staff who helped dress Lucy in the mornings would forget to ask her to wear them.

As Lucy’s dementia progressed, she began to not recognise her own reflection if she didn’t ‘have her teeth in’. The physical effect of so many missing teeth was to make her look much older and frailer, her cheeks sucked in and her lower jaw receding. She would look unhappy and never smile without her dentures in place.

In the last few months of Lucy’s life, her family found it increasingly difficult to engage staff about oral health on her behalf.

Her son reflects, “It seemed to us that oral hygiene was completely neglected and just not a priority. It is hard to say exactly how this impacted upon Mum’s emotional state as she found it difficult to communicate by this stage, but it made the family feel very sad to see her looking so unhappy, unhealthy and uncomfortable. We felt she was no longer being treated with dignity, kindness and respect.”



Practical skills

Dysphagia

• Dysphagia is the medical term for difficulty in swallowing.

• It is a series of symptoms rather than a disease.

• One in 10 people over the age of 65 have swallowing problems.

• The three main health complications of dysphagia are under-nutrition, dehydration and pneumonia.

• A professional assessment (by a health professional such as a speech and language therapist) should be carried out for individuals experiencing dysphagia and a specific oral health plan should be established.

Signs that may indicate dysphagia include:

• Problems with eating or drinking, or a feeling of obstruction.

• Gurgly, wet or hoarse voice, frequent clearing of throat.

• Coughing or choking with or after food and/or drink.

• Taking time with meals or changed eating habits.

• Food remaining in mouth.

• Recurrent chest infections/pneumonia or unexplained temperature spikes.

• Drooling/dribbling.

• Refusing certain type of food.

• Difficulties or pain with chewing or swallowing.

• Unplanned weight loss.

Key message:Eating, drinking and swallowing problems are common among older people and require special assessment and care.


Additional points when caring for someone with dysphagia

If the resident is on a ‘nil by mouth’ regime:• A clean, healthy mouth is essential for good overall health, but is often forgotten

when someone is unable to eat or drink easily.

• Ensure all care staff are aware of the importance of regular oral care.

• Plaque still forms in the mouths of people who are on the following regimes: nil by mouth; PEG-fed and oxygen therapy.

Percutaneous Endoscopic Gastrostomy (PEG) and Nasogastric feeding:• Residents receiving food and drink via a non oral route may be more prone to oral

disease and discomfort than in those receiving nutrition orally.

• Dry mouth is very common due to the effects of the restriction of oral food and fluids plus mouth breathing, constant open mouth and nasal oxygen, in intubated residents.

• It is recommended to use non foaming toothpaste with a small, soft toothbrush plus consider a suction toothbrush for those residents with severe swallowing difficulties.

Person with natural teeth:• Check for residual food and medication prior to brushing. Any debris should be

removed with moist non-fraying gauze on a gloved finger.

• A small headed toothbrush and a smear of non-foaming toothpaste (without sodium lauryl sulphate) should be used to clean natural teeth.

• If the resident is still able to carry out their own oral care, ensure they are aware of the importance of good oral hygiene.

Person with dentures:• Care must be taken with denture adhesives.

• The speech and language therapist or dietitian may be able to offer assistance and advice if a person has difficulties.

• If the resident is unable to tolerate a toothbrush, a dampened non-fraying gauze swab may be used.

• Do not use mouthwash where residents have dysphagia – this is due to the risk of choking or aspiration.

• Lubricate lips with a water-based saliva replacement gel to stop them feeling dry or cracked. Petroleum lip balms should be avoided, due to flammability and aspiration risk.

• Even if someone is not eating or drinking, they should continue to be seen by the dentist.


Practical skills

Palliative and end-of-life care

Mouth care should be carried out regularly to ensure the resident is kept as comfortable as possible. It is essential that good and thorough care and a thoughtful approach be adopted. All care should be fully documented. The importance of regular mouth care should be explained to the resident’s family or carers at this sensitive time.

If resident has a healthy mouth:

• Assess daily for changes.

• Clean teeth using a soft, small-headed toothbrush and fluoride toothpaste after each meal and at bedtime. Keep any dentures scrupulously clean.

• Damp gauze (non-fraying type, which has been thoroughly wetted in clean running water) wrapped around a gloved finger may be used if the resident is unconscious or unable to tolerate a toothbrush.

• Apply water-based saliva replacement gels or aqueous cream to lips.

Key message:In palliative and end-of-life care, mouth care should be carried out regularly to ensure the resident is kept as comfortable as possible.

Percutaneous Endoscopic Gastrostomy (PEG) and Nasogastric feeding.

It is extremely important that oral health and mouth comfort is maintained for these residents.

They may be more prone to oral disease and discomfort than in those receiving nutrition orally.

Dry mouth is very common due to the effects of the restriction of oral food and fluids plus mouth breathing, constant open mouth and nasal oxygen, in intubated residents.

It is recommended to use non foaming toothpaste with a small, soft toothbrush plus consider a suction toothbrush for those residents with severe swallowing difficulties.

When brushing is not possible, the tongue and other areas of the mouth can be cleaned with a gloved finger wrapped in damp gauze.


Oral health assessment

Key message:Using an oral health assessment tool will highlight any areas where residents need specific care and support. Using it for reassessments will indicate any changes that may need action.

All residents should have an oral health assessment when they move into the care home irrespective of the length of their stay, with the result recorded in their care plan. Care staff should start by asking the following questions:

How do you usually manage your daily mouth care and what help would you like?

What dental aids do you currently use? For example, manual or electric toothbrush, mouthwash, floss.

Do you have dentures, and if so are they marked with your name? If not, would you like them to be marked?

When did you last see a dentist, and who did you see?

If you don’t have a dentist, would you like help to fine one?

• Helps identify residents who have a current oral health problem which may require the attention of a dentist.

• Highlights those who are particularly at risk of future problems because of physical or cognitive impairment or poor oral care habits.

• Allows the development and implementation of an individual oral care plan which indicates the daily care assistance required.


Tools

Mouth care plan

A mouth care plan should be developed as a result of the findings of the oral health assessment. The completed risk assessment should highlight any need for a dental check-up or urgent appointment with the resident’s dentist. Information on help in finding an NHS dentist and referring to the Special Care Dental Service can be found on p55 – Professional Support.

The oral health assessment will also show details of any specific individual care requirements of the resident, either as a result of their oral health status or because of cognitive or physical impairments. These individual requirements should be documented in the care plan. This will inform staff who carry out daily personal care, what kind of assistance each resident requires.

The care plan should be reviewed each time the resident’s oral health is reviewed.

Care staff knowledge and skills

Care staff need to know how and when to reassess the oral health of a resident, and how to support residents with their daily mouth care to:

Clean their dentures (brushing, removing food debris, removing dentures overnight.

Use their choice of toothbrush, either manual or electric/battery powered, and mouth care products.

Brush their natural teeth at least twice a day with fluoride toothpaste.

Use their choice of cleaning products for dentures.

They also need to understand how dental pain or a mouth infection can affect residents’ general health, wellbeing and behaviour.

Make sure staff know who to ask for advice, how and when to report any concerns about a resident’s oral health, and how changes in a person’s condition might affect their ability to manage their mouth care.


Accurate record-keeping by care staff is essential and this requirement to document care often acts as a useful prompt. It is also important that any reasons for non-cooperation on the part of the resident are recorded in notes in a way that highlights any on-going deficiencies in essential care, to enable this to be addressed.

Daily documentation of oral care

Some people may not need support to clean their teeth or dentures. This should be monitored so that support can be offered if their requirements change.

Equality and diversity considerations

Care staff should know what to do if a resident declines support with mouth care, in line with the Mental Capacity Act and local policies about refusal of care (see also NICE’s information on your care). People should not be forced to receive mouth care against their wishes. However, repeated refusal should not be ignored and some people may need additional support to feel comfortable receiving mouth care.

Reasonable adjustments should be made, in line with the Equality Act, to ensure that people with disabilities can receive the mouth care which is most suitable for them.

www.gov.uk/government/collections/mental-capacity-act-making-decisions

www.nice.org.uk/about/nice-communities/public-involvement/your-care

Examples of oral health assessment, mouth care plan and daily oral care record sheets are provided in the following pages.

Remember!

Always document the oral care that is carried out.

Oral health risk assessment: Appendix 1, page 49

Mouth care plan: Appendix 2, page 51

Daily oral care: Appendix 3, page 53

These can be photocopied or use to create your own versions.


Appendix 1

Oral health risk assessment

Name of resident Date of birth Date of assessment

Circle which is appropriate Suggested outcome/actions

1 Does the resident have any of their natural teeth?

No Yes Don’t know

Encourage independence with cleaning teeth morning and night. Use a small headed toothbrush and fluoride toothpaste.

2 Does the resident wear dentures?

Specify:

No Yes Don’t know

Dentures must be cleaned morning and night by brushing with un-perfumed soap and water or normal toothpaste and toothbrush. Encourage resident to rinse denture after meals.Gently clean the oral mucose with moist gauze.Dentures must be left out at night in plain water in a denture pot marked with the residents name.

Upper

Lower

a) If YES, are dentures labelled? No Yes If available, use kit for denture marking.

b) If YES, how old are dentures? Less than 5 years

More than 5 years

Don’t know

Consider referral to dentist for assessment of old dentures.

3 Does the resident need help to clean teeth/dentures?

No Yes May need supervision/help with mouth care.

4 Does the resident complain of suffering any oral problems?

Please tick: Facial swelling Painful natural teeth Non-healing ulcers Decayed/broken teeth Bleeding gums Lost dentures Denture problems

No Yes to any

Discuss with resident and/or family as appropriate and make an urgent appointment with their dentist. Refer to specialist service if required.

5 Does the resident have their own dentist?

No Yes Don’t know

Consider referral to dentist for check up if the resident wishes.

If YES, record name and address of dentist

Is the resident exempt from NHS dental charges?

No Yes Don’t know

Discuss with resident/and/or family as appropriate if eligible for help with NHS charges.

6 Date of last dental treatment Less than 2 years ago

More than 2 years ago

Don’t know


7 Is the resident taking medication? No Yes Consider drugs which may have oral side-affects. Check with pharmacist.

8 Does the resident complain of a dry mouth?

No Yes Clean lips and oral soft tissues with a water moistened gauze and protect with water-based gel.Offer frequent fluids and/or iced water.If symptoms persistent, refer to dentist.

9 Does the resident smoke? No Yes Note amount per day.Consider smoking cessation.

If further investigation required, please refer to dentist.

Referred to dentist? Yes No Advice from dentist? Yes No Resident refused referral? Yes No

A response in a red box – contact dentistA response in an orange box – may require more intensive oral health input, consider seeking advice from a dental professional.


Support required

Independent Some assistance Fully dependent

Assistance needed:

Regular mouth care plan ONLY

Using:

Electric toothbrush

Manual toothbrush

Brand of preferred toothpaste: ________________________________________________________________________

Mouthwash

Denture cleaner

Other eg. interdental brushes, floss

Regular mouth care with additional support

To include:

Toothbrushing aids

Specialised toothbrush (eg. Superbrush or Collis Curve) ___________________________________________________

Specialised toothpaste (eg. Duraphat or OraNurse) _______________________________________________________

Chlorhexidine gel

Treatment (Gel) for dry mouth

Other eg. mouth props ______________________________________________________________________________

Outcome from referral / other relevant information:

Mouth care planDate

plan startedReview

date Name of resident Date of birth

Dentist contact details:

Last visit within one year: Yes No

Regular care Self caringBrush teeth with

fluoride toothpaste at least twice daily

If debris is present, consider

Advice on technique

Increase staff support

Appendix 2


Daily oral care

Name: Month:

Day Non-compliance code/notes InitialsPlease tick: Please tick:

AM PM AM PM1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Codes: reasons for non-compliance

Resident non-cooperative A Patient asleep B Staffing levels C Other D

• Ensure natural teeth are brushed twice a day with a fluoride toothpaste.• Ensure dentures are cleaned every night and left to soak overnight in plain water.

Appendix 3


Professional Support

How to find an NHS dentistEveryone should be able to access good-quality NHS dental services. There is no need to register with a dentist in the same way as with a GP because you are not bound to a catchment area. Simply find a dental practice that’s convenient and phone them to see if any appointments are available. If a resident does not have a regular dental practice or is new to the area, you can search for a NHS dentist near you using these sites.

www.wessexdentalhelpline.nhs.uk www.nhs.uk/using-the-nhs/nhs-services/dentists/

If after contacting several dental practices you still can’t find a dentist accepting NHS patients, you should call NHS England’s Customer Contact Centre on 0300 311 2233.

Your local Healthwatch also may be able to give you information about services in your area.

If NHS England has been unable to help you find a dentist and you want to raise your concerns about this, contact them on: • Email: [email protected]• Telephone: 0300 311 2233• Visit the NHS England website: www.england.nhs.ukIf you’re still not satisfied with NHS England’s response, you can take your complaint to the Parliamentary and Health Service Ombudsman.

Dental emergency and out-of-hours careIf a resident requires urgent treatment, please contact their usual dental practice as they may be able to see them or direct you to an urgent care dental service. If a resident does not have a regular dentist, contact NHS 111 for advice on where you can get urgent care.

Special Care Dental ServiceThis service provides a quality dental service for people of all ages who require specialised dental care that is not available in a General Dental Practice.

People in this category include those with a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability, including those who are housebound. The service seeks to meet individual needs through the provision of community dental clinics and highly skilled staff. All clinical staff are registered with the General Dental Council.

To access the service a resident must be registered with a Hampshire General Medical Practitioner (GP). A health professional (Doctor, Nurse, Dentist), carer or family member can complete the referral form on their behalf. Referrals will need to include information about exemption status. Normal NHS dental charges apply.

Contact UsFor general enquiries please contact:

• Solent NHS Trust Dental Single Point of Access Dental Administration Office, Level A, Royal South Hants Hospital, Brinton’s Terrace, Southampton SO14 0YG

Telephone: 0300 300 2014 Option 3 Email: [email protected]

General dental practices and community dental services

http://www.wessexdentalhelpline.nhs.uk

http://www.nhs.uk/using-the-nhs/nhs-services/dentists/

mailto:england.contactus%40nhs.net?subject=

http://www.england.nhs.uk

mailto:SNHS.CentralPointofReferral%40nhs.net?subject=


Useful links

• British Dental Association The professional association and trade union for dentists in the UK. www.bda.org

• British Dental Health Foundation An independent charity working to bring about improved standards of oral health care in the UK and around the world. Helpline: 0845 063 1188 www.dentalhealth.org.uk

• British Society of Disability and Oral Health The aim of the society is to bring together all those interested in the oral care of people with disabilities. Offers a range of guidance documents. www.bsdh.org.uk

• British Society of Gerodontology The aim of the society is to protect, maintain and improve the oral health of older people. www.gerodontology.com

• Alzheimer’s Society www.alzheimers.org.uk/get-support/daily-living/dental-care

• Oral care and people with learning disabilities: Public Health England, Mar 2019. www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities

• Oral Health Foundation: learning disabilities and oral health www.dentalhealth.org/learning-disabilities-and-oral-care

• Clinical Guidelines and Integrated Care Pathways for the Oral Health Care of People with Learning Disabilities www.wales.nhs.uk/document/214890

http://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities

http://www.gov.uk/government/publications/oral-care-and-people-with-learning-disabilities/oral-care-and-people-with-learning-disabilities

http://www.dentalhealth.org/learning-disabilities-and-oral-care

http://www.wales.nhs.uk/document/214890

© Copyright reserved Solent NHS Trust

December 2019. Version 1. Designed by NHS Creative – CS49529

Developed by the Solent NHS Trust Special Care Dental Service in partnership with Hampshire County Council

Publication date: December 2019


Appendix 1

Oral health risk assessment

Name of resident Date of birth Date of assessment

Circle which is appropriate Suggested outcome/actions

1 Does the resident have any of their natural teeth?

No Yes Don’t know

Encourage independence with cleaning teeth morning and night. Use a small headed toothbrush and fluoride toothpaste.

2 Does the resident wear dentures?

Specify:

No Yes Don’t know

Dentures must be cleaned morning and night by brushing with un-perfumed soap and water or normal toothpaste and toothbrush. Encourage resident to rinse denture after meals.Gently clean the oral mucose with moist gauze.Dentures must be left out at night in plain water in a denture pot marked with the residents name.

Upper

Lower

a) If YES, are dentures labelled? No Yes If available, use kit for denture marking.

b) If YES, how old are dentures? Less than 5 years

More than 5 years

Don’t know

Consider referral to dentist for assessment of old dentures.

3 Does the resident need help to clean teeth/dentures?

No Yes May need supervision/help with mouth care.

4 Does the resident complain of suffering any oral problems?

Please tick: Facial swelling Painful natural teeth Non-healing ulcers Decayed/broken teeth Bleeding gums Lost dentures Denture problems

No Yes to any

Discuss with resident and/or family as appropriate and make an urgent appointment with their dentist. Refer to specialist service if required.

5 Does the resident have their own dentist?

No Yes Don’t know


If YES, record name and address of dentist

Is the resident exempt from NHS dental charges?

No Yes Don’t know

Discuss with resident/and/or family as appropriate if eligible for help with NHS charges.

6 Date of last dental treatment Less than 2 years ago

More than 2 years ago

Don’t know


7 Is the resident taking medication? No Yes Consider drugs which may have oral side-affects. Check with pharmacist.

8 Does the resident complain of a dry mouth?

No Yes Clean lips and oral soft tissues with a water moistened gauze and protect with water-based gel.Offer frequent fluids and/or iced water.If symptoms persistent, refer to dentist.

9 Does the resident smoke? No Yes Note amount per day.Consider smoking cessation.

If further investigation required, please refer to dentist.

Referred to dentist? Yes No Advice from dentist? Yes No Resident refused referral? Yes No

A response in a red box – contact dentistA response in an orange box – may require more intensive oral health input, consider seeking advice from a dental professional.


Support required

Independent Some assistance Fully dependent

Assistance needed:

Regular mouth care plan ONLY

Using:

Electric toothbrush

Manual toothbrush

Brand of preferred toothpaste: ________________________________________________________________________

Mouthwash

Denture cleaner

Other eg. interdental brushes, floss

Regular mouth care with additional support

To include:

Toothbrushing aids

Specialised toothbrush (eg. Superbrush or Collis Curve) ___________________________________________________

Specialised toothpaste (eg. Duraphat or OraNurse) _______________________________________________________

Chlorhexidine gel

Treatment (Gel) for dry mouth

Other eg. mouth props ______________________________________________________________________________

Outcome from referral / other relevant information:

Mouth care planDate

plan startedReview

date Name of resident Date of birth

Dentist contact details:

Last visit within one year: Yes No

Regular care Self caringBrush teeth with

fluoride toothpaste at least twice daily

If debris is present, consider

Advice on technique

Increase staff support

Appendix 2


Daily oral care

Name: Month:

Day Non-compliance code/notes InitialsPlease tick: Please tick:

AM PM AM PM1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Codes: reasons for non-compliance

Resident non-cooperative A Patient asleep B Staffing levels C Other D

• Ensure natural teeth are brushed twice a day with a fluoride toothpaste.• Ensure dentures are cleaned every night and left to soak overnight in plain water.

Appendix 3

Mouths Matter - documents.hants.gov.uk · • A healthy mouth gives confidence and should be valued...

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