Oral Care for Paediatric Hospice Patients

1. Oral Care for Paediatric Hospice Patients Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

2. Aims and Objectives Aims To provide an overview of dentalhealth. Objectives By the end of the session all staff will: Recognise what a healthy mouth should look like. Have a knowledge of the decay process. Be able to introduce/adapt an oral health routine for all patients Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

3. What does a healthy mouth look like? The mucous membranes should be bright pink, smooth, glistening, uniform and moist The gums should be pink (may be darker in dark skinned children) The tongue should have papillae which give the tongue its characteristic rough appearance Permanent teeth will appear yellower than deciduous teeth Teeth should appear smooth and shiny(food and plaque free) Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

4. Oral Conditions Gingivitis Cause Poor oral hygiene regime Signs / Symptoms Bleeding on brushing Red, swollen gums Sudden reluctance to eat certain foods Treatment / Prevention Good regular tooth brushing Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

5. Oral Conditions Gingivitis (cont) If necessary Chlorhexidine gluconate may be used in gel or mouthwash (alcohol free) form Mouthwash can be applied on damp gauze Use at different time of day to tooth brushing Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

6. Oral Conditions Periodontitis Advanced condition of gingivitis May not be as common, except on older patients Need to maintain good oral hygiene regime Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

7. Oral Conditions Candidiasis / Thrush Cause Opportunistic yeast infection : Candida albicans Especially in patients with lowered immune system Poor oral hygiene may increase risk Signs / Symptoms Thick white or cream deposits on mucous membranes Underlying tissues inflamed and raw Easily wiped off Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

8. Oral Conditions Candidiasis Prevention Good oral hygiene regime can lower risk If detected in the mouth, alert trained medical staff as prescription medication may be necessary Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

9. Oral Conditions Herpes Cause Herpes Simplex virus Signs Outside of the mouth Ulcers, blisters and inflammation on the lips Inside the mouth Blisters on the tongue, gum or throat May be misdiagnosed Can be very painful Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

10. Oral Conditions Herpes Symptoms Swollen, tender glands Pain on swallowing and eating Saliva collection and drooling High fever Treatment Topical anaesthetic gel Analgesics Soft diet Fluids • Oral Hygiene • May be difficult • Soft toothbrush • Chlorhexidine gluconate (prescription) • This virus is highly contagious. Ensure good infection control and avoid hand eye contact. Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

11. Oral Conditions Xerostomia Dry mouth May be more difficult to detect Mouth becomes sore and swallowing and chewing difficult Increases risk of decay Can be a side effect of some drugs, radiotherapy and mouth breathing Artificial saliva, frequent sips of water, ice chips and sugar-free chewing gum, if appropriate, can be used to alleviate symptoms Excellent oral hygiene should be maintained Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

12. Other Oral Conditions • Mouth ulcers • Gingival overgrowth • Due to certain medications such as Epilim • If you see anything in the mouth that you are unsure of a dentists opinion should be sought. Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

13. Good Oral Health Routines Essential that good oral hygiene regimes establish early on in care Oral Assessments should be made at admission and a care plan drawn up to include oral hygiene and diet Oral hygiene routine added to daily care plan to ensure that routine carried out Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

14. The Importance of Good Tooth brushing Why is good oral hygiene important for your patients? • Removes plaque on the teeth • Prevents oral infections e.g.: thrush • There is a link between gum disease and other diseases such as heart disease or diabetes Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

15. Toothbrushes Manual toothbrushes • Doesn’t have to be fancy • Use children’s toothbrushes for specific age ranges, if appropriate • Use a small headed toothbrush with rounded ends • Medium bristled toothbrush • If patient has a painful mouth, use a soft brush • Replace the toothbrush when worn Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

16. Toothbrushes Electric toothbrushes • Clinical evidence that an electric toothbrush can be beneficial if used correctly • Try and get one with an oscillating head • Use a rechargeable one rather than battery operated • Different heads can be used • Different brushing technique to manual brushing • May not be tolerated but may also motivate lazy brushers! Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

17. Adaptive Aids / Tips • If the patient is able to brush their own teeth, toothbrushes can be adapted for easier use • Sponge balls • Bicycle handlebars • Modelling clay • Rubber bands • If the patient is unable to brush their own teeth • Use a second toothbrush if the patient tends to bite • Use a finger guards to prevent the patient biting you! • Stroking the cheek can help with patients who clamp their mouth shut • Pressing a pressure point on the chin can help with gagging Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

18. Other Tools • Fluoride toothpaste • For children under 3 use a toothpaste containing 1000ppm – smear on brush • For children over 3 a family toothpaste containing at least 1350 ppm fluoride can be used – size of a pea • A high fluoride toothpaste may be prescribed for children 10+ • Spit out excess – do not rinse • Mouthwash • Needs to be alcohol free • Use at different time to tooth brushing • Disclosing tablets/Solution - Highlights missed plaque - Provides motivation - Can use disclosing solution if patient can’t chew tablets Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

19. How Do I Brush A Child’s Teeth? Sit the patient on a comfortable chair. Place a towel around the patient to catch drips Either stand behind or slightly to the side of the chair If patient is bed bound roll patient on their side If the patient tires easily do one side at a time with a rest in between Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

20. How Do I Brush A Child’s Teeth? Tooth brushing should take 2-3 minutes Brush two or three teeth at a time using a circular shape Angle the toothbrush towards the gum margin For an electric toothbrush, brush teeth individually a quadrant at a time If you are unsure how hard to brush try practicing on a colleague or brushing your hand Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

21. How Do I Brush A Child’s Teeth? • Have a routine method of tooth brushing • prevents areas being missed • If patient will allow it, brush the inside surfaces in the same way especially lower anteriors • Biting surfaces can then be brushed using a scrub motion Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

22. Infection Control • Each patient to have own toothbrush • After use toothbrushes can be stored in antiseptic mouthwash • Especially if oral condition exists • Wear fresh gloves with each patient to prevent cross infection • Dispose of any waste as appropriate Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

23. SUGAR IN THE MOUTH Sugar + Plaque in the mouth = ACID Acid attacks the teeth and leads to decay As plaque reappears in the mouth 20 minutes after tooth brushing, restricting sugar is the only way of preventing decay The amount of sugar is not as important as the frequency it is consumed Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

24. SUGAR Sugar makes food taste sweet but is also used as a preservative Hidden sugars occur in foods that are not commonly thought of as containing sugar → they may not be sweet Peanut Butter Tomato Sauce Baked Beans Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

25. DRINKS Squashes, juices and sports drinks have sugar including those that say “no added sugar”, “low sugar” or “naturally occuring fruit sugars”. Even fresh fruit juices and smoothies contain natural sugars. Fizzy drinks usually contain lots of sugar but they also contain acids which erode the tooth surface Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

26. SUGAR FREE MEDICINE Some medication contains sugar It is common in medicines like : Cough drops Cough syrups Throat sweets Tablets that have a sugar coating Other medicines given as syrups Make sure that any prescription or over the counter medication is sugar free Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

27. Preventing Decay Ingredient labels will tell you if the food item has sugar Comes in many form Look for words ending in “-ose” Fruit juices and dried fruit contain sugar Others include yoghurt, crisps and cereal bars Sugar can not banned completely but should be eaten sensibly Sugary foods and drinks should be eaten at meal times only Sweets, biscuits, cakes and chocolates should be kept and eaten after meals as puddings Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

28. Between meal non-sugary foods and drinks should be eaten Drinks : water and milk Good snacks fresh fruit and raw vegetables (not fruit juices or smoothies) bread sticks toast with Marmite or butter plain popcorn with no sugar or salt nuts or seeds – if appropriate pitta bread Preventing Decay Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

29. Open cups should be used where possible - If using a feeder cup try to use water only and minimise the length of time it is used for. “One hour to bed” rule No snacks or drinks 1 hour before bed Nothing to eat or drink after tooth brushing at night Only water through the night Some medical conditions may cause additional dental concerns Eg: Peg feeding and Naso-gastro tubes Preventing Decay Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

30. THE GOLDEN RULES OF SUGAR Keep foods and drinks with sugar in them to meal times only Between meals foods with sugar and drinks that are sugary and fizzy should be avoided Reduce frequency of snacking between meals Water or milk should be drunk between meals Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

31. Referrals • At the oral assessment check whether patient has a general dentist • May prefer to see usual dentist • If patient has no dentist, parents can self-refer to Community Dental Services • Centres in Ipswich, Bury St Edmunds, Newmarket and Sudbury Tel: 01473 685964 (Chantry – Ipswich) Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust

32. Resources • Adaptive Aids • Dento-Care • Telephone: 020 8459 7550Web: http://www.dentocare.co.ukEmail: sales@dentocare.co.uk • British Society for Disability and Oral Health • Web: http://www.bsdh.org.uk Suffolk Community Healthcare is responsible for providing NHS services in the Suffolk area and is hosted by Suffolk Primary Care Trust