Learning Outcomes

1. Learning Outcomes • Summarise the importance of the different oral care forms • Carry out an Oral Health Risk assessment • Describe the techniques and strategies that may help those residents with Dementia, with specific reference to those resisting oral care • Recognise the need for specialist Oral care

2. National Care Standards: Care Homes for Older People

3. Good Oral Health is Important for Overall Health • Oral bacteria from a dental abscess or other oral infection may enter the bloodstream and cause septicaemia • Oral bacteria can cause specific heart damage (endocarditis) in people who have pre-existing heart value problems. • Poor oral hygiene is a key factor for pneumonia and respiratory tract infections in vulnerable residents • 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, any infection contributing to a rise in blood glucose levels

4. How the Key messages differ for dependent older people • Spit don’t rinse – may not be appropriate for people with a dry mouth. Some people unable to spit should use a non-foaming toothpaste • Many older people need or prefer high calorie food and drinks. Always remember enjoyment of food is important for residents • Oral Care should be enhanced • Regular dental visits are still important for older people

5. Dental Decay • What is decay • Demineralisation/acid attack • Sugar mixed with bacteria • Last up to 1-2 hours • Dental erosion on – different from demineralisation is wearing of enamel • How is it prevented • Reducing number of acid attacks • Brushing teeth with fluoride toothpaste • People with dry mouth more prone to decay

6. What is Dental plaque? • Plaque and tartar can form above and below the gum • Any irregularities around the teeth (crooked teeth, overhanging edges on fillings, partial dentures) will encourage the build up of plaque • Plaque still forms in the mouths of people on the following regimes: • Nil by mouth; PEG (percutaneous endoscopic gastrostomy) fed; oxygen therapy

7. Gum Disease • Early stage - Gingivitis • Advanced stage - Periodontitis

8. Caring for Natural Teeth • Add Pictures

9. Caring for Dentures • Residents may wear full dentures or partial dentures • ( often called a plate) • It can sometimes be difficult to tell what are dentures and what are natural teeth, so a through oral assessment should be carried out shortly after admission • All dentures should be marked with the residents name or other form of identity • Some residents can be reluctant to remove their dentures • In this case encourage removal for minimum of 20 mins then soak in disinfecting solutions

10. Removing Partial Dentures If possible seek advice from a dental professional especially if caring for partial dentures is new to staff It the resident is able ask them to remove the partial denture 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

11. Inserting Dentures Full Dentures Dentures should be rinsed under clean water before being replaced in the resident’s mouth Encourage independence if the resident is able to do this themselves Replace upper denture first Gently insert denture at angle, then rotate 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

12. Good practice – Disinfecting Dentures • Effervescent cleaners not always effective especially at eliminating denture related infection • Plastic dentures should be soaked in solution of sodium hypochlorite • 20 mins soaking is recommended then place in water • Do not store in reach of residents with dementia • Denture containing metal should not be soaked in this solution • Instead used Chlorohexidine 0.2%may need prescription

13. Dry mouth(xerostomia)How important is saliva?Group work

14. Dry Mouth • Helping a resident with a dry mouth • Regular sips of water • Saliva substitutes – gels and sprays • Use as often as required • People with dry are more at risk of tooth decay • High fluoride toothpaste (prescribed by a dentist) or fluoride mouthwashes may be helpful • Better oral care for dependent older people

15. Caring for Soft Tissue • For people who wear dentures and those who have no teeth at all. The soft tissues should be cleaned regularly • Sponge sticks – these are not recommended as there is a risk of the foam head detaching from the stick during use. This presents a serious choking hazard and there is a medical alert in place • They do not remove plaque from tooth surfaces • If they are used, it should only be to moisten the mouth or clean the soft tissue • They must be discarded after single use

16. Fungal Infections • Fungal infections can show as an area of redness under an upper denture (denture stomatitis) or as generalised redness or as white patches (oral thrush) • Pics of denture stomatitis and oral thrush

17. Soft Tissue Conditions

18. Soft Tissue ConditionsInfections • Angular Chelitis • Corners of the mouth are cracked, red and crusting • Angular Chelitis can be caused by a fungal or bacterial infection • Diagnosis of soft tissue infections will be made by a dentist or doctor

19. Mouth Ulcers Causes There are numerous causes of ulcers in the mouth, for example denture trauma, reaction to drugs, underlying disease or oral cancer. Seek advice from a dental professional even if ulcers are painless.

20. Oral Cancer? • Oral cancer can affect the lips, mouth or throat • Any red, white or speckled patches • Ulcers or sores that do not heal within two weeks – these must be investigated by a dentist urgently • Lumps or bumps in the mouth or on the lip • Unexplained speech patterns or difficulty in swallowing • IF IN DOUBT GET CHECKED OUT

21. When to refer to a Dentist or seek advice from a Dental professional • Signs of dental disease • Signs of gum disease • Persistent dry mouth • Ulcers after 2 weeks, even if painless • Swallowing problems • Any signs of oral cancer

22. Observe and Report • Oral problems often go undetected because staff lack confidence to look in a resident’s mouth • By regularly checking a residents mouth you will be able to note any changes or problems • Always record the detail in a residents personal notes • Any changes should be reported to either the person in charge or a dental professional

23. Infection Prevention and Control • Staff training on up to date infection prevention and control • Ensure water source being used is drinking water • Rinsing of toothbrushes • Denture containers • DVD – Preventing infection in Care

24. Step One

25. Step Two

26. Step Three

27. Supporting patients with Dementia • KEY MESSAGE: • When a resident becomes uncooperative and won’t let you near their mouth – think! Are they in pain? • It may be the only way that the person can communicate fear, pain or distress.

28. Supporting patients with Dementia • Do all you can to encourage independence • Time and Place • Develop a routine • More than one care assistant may help, or a person may respond better to well-known member of staff • Quiet distraction-free environment with good light • Always consider the dignity of the resident

29. Supporting Resident's with Dementia • Bridging • Chaining • Hand over hand • Distraction – • Rescuing

30. Supporting Resident's with Dementia • The legislation that covers caring for people who are not able to understand or consent to necessary care is the adults with Incapacity (Scotland) Act 2000 • The Mental Welfare Commission offer advice • If carers are still unable to carry out oral care, consult with: • Dementia Liaison or community mental health teams • The Residents Dentist • Local NHS helpline

31. Dysphagia • Signs that may indicate dysphagia include: • Problems 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 easting habits

32. Dysphagia - Symptoms • Food remaining in the mouth • Recurrent chest infections/pneumonia or unexplained temperature spikes • Drooling/dribbling • Refusing certain types of food • Difficulties or pain with chewing or swallowing • Unexplained weight loss

33. Caring fro a person with Dysphagia • 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 • Care must be taken with denture adhesives • The speech and language therapist or dietician will carry out a swallowing assessment.

34. Caring fro a person with Dysphagia • Nil by mouth • Clean healthy mouth essential, but often forgotten • All staff must be aware of importance of regular oral care • Plaque still forms in the mouths of people on nil-by-mouth, PEG-fed and oxygen therapy • Requires additional care

35. Palliative and end-of-life care • In palliative and end of life care, mouth care should be carried out regularly to ensure the resident is kept as comfortable as possible • All care should be fully documented • The importance of regular mouth care should be explained to the resident’s family at this sensitive time • Assess daily for changes • Access to specialist palliative care advice is available from specialist palliative care teams based in the community, general hospitals and hospices

36. Palliative and end-of-life care • If a resident has a healthy mouth • Access daily • Clean natural teeth using soft, small-headed toothbrush and fluoride toothpaste • Keep any dentures scrupulously clean • Damp gauze wrapped around gloved finger if resident is unconscious or unable to tolerate toothbrush • Water-based saliva gels or aqueous cream to lips

37. Palliative and end-of-life care • If the resident has a painful mouth • If possible, identify cause. Refer to dentist urgently • If caused by dry mouth, water based saliva gels can help • If dietary advice is required, consult with dietician or nurse

38. Common oral problems in palliative care • If painful mouth ulcers are present: • If possible, identify cause and refer to dentist urgently. • If there is general redness of the soft tissues: • This could be a bacterial infection. The bacteria can also cause respiratory tract infections such as pneumonia • If a resident is receiving cancer treatments and oral thrush develops: • Oral thrush in cancer patients can be very serious, preventing the person swallowing. Specialist advice is crucial.

39. Short answer questionnaire • Intermediate practical skills competency framework

40. Finish Thank you Please remember to complete your Evaluation