What’s all the fuss with oral care ?

Emma Riley

Healthcare Services Director

RIS Healthcare

oral health for adults in care homes Nice guidelines 5th July 2017

• “Staff should understand the importance of residents oral health and the potential impact on their general health, well being and dignity”

NICE will be marking homes on levels of oral care

• An 80-year-old man with a history dementia, Parkinson’s disease, seizures

• Admitted to hospital from his nursing home with a two day history of shortness of breath.

• He was unable to provide a history due to his dementia, although the possibility of aspiration, (swallow) of a denture was suggested by staff.

• Examination revealed reduced air entry on the right side and a chest X-ray showed collapse of the right lung but no foreign body. He could not tolerate a chest CT as he was not able to lie flat due to breathlessness

• Due to his significant medical history palliative therapy was chosen and he died the following day.

• Post mortem revealed… Graphic Photo Alert!!

Failure to remove a dangerous denture

Sorry its graphic

Mouthcare is changing

• 24.7% of 5 year old's have tooth decay, 1 in 4 will have decay when they start school

• Almost half of UK adults have a fear of the dentist, 12% of theses suffer from extreme dental phobia

• 700,00 people in the UK on the Autism spectrum, 1 in 100

• 1.5 million in the UK with learning disabilities

• 850,000 people in UK with Dementia figures to rise to over 1 million by 2025- 70% of people in care homes have Dementia

• There are 2.5 million people in the UK living with cancer

• Over the past 20 years Mouth (oral) Cancer figures have risen by 68%

Chronic

Conditions kill

39.5 Million

every year

Oral Diseases

affect 3.9

Billion

worldwide

Putting the mouth back into the

body

Treating the mouth

with the respect it

deserves

The mouth (oral cavity)

• Lips

• Inside of the lips

• Cheeks

• Teeth and Gums

• Front two-thirds of tongue

• Floor of mouth

• Below tongue

• Upper and lower jaw

• Salivary Glands

• Bony roof of mouth (hard palate)

Think mouth, Think health

Oral Health General Health

A two way relationship

Poor oral health has been

linked to general health

Poor oral health can cause

• Behaviour Problems

• Inability To Eat and speak

• Diet, Nutritional And Hydration Problems

• Weight Changes

• Problems With Social Interactions

• Medical Complications-aspiration Pneumonia

• Poor Quality Of Life

Would you ignore this?

But this gets ignore…….Why?

@NHS_HealthEdEng @MCM_HEKSS #mouthcare

Jacks story – 25th January 2016

82 year old male

Sent from hospital to home after long stay

Jack wasn’t eating or drinking

This improved after 24 hours of mouth care

Sadly jack passed shortly after

Elizabeth’s story

• Hospitals are trying to get oral care classed a ‘6th harm’ in long term hospitalisation

• Elizabeth McGaw, 87, died after her denture had to be surgically removed. She was admitted from a care home in Scotland in December 2006.

• Coroner concluded although poor oral care was not the cause of death, it was contributing factor

Vap-Ventilator Associated Pneumonia

• VAP- ventilator associated pneumonia (vap) is pneumonia occurring in a patient within 48 hours or more after intubation with an endotracheal tube or tracheostomy tube and which was not present before

• VAP increases length of icu stay by 28% and each incidence of vap is estimated to generate an increased cost of £6000- £22000!!!!

• IT’S A TICKING TIMEBOMB!!!!!!

• BJMP 2009:2(2) 16-19

Defining HAP and CAP

• Hospital-Acquired Pneumonia (HAP)

• is defined as pneumonia that occurs 48 hours or more after hospital admission and that was not present at the time of admission.

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/health-care-associated-pneumonia/

• Community-acquired pneumonia (CAP)

• Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities.

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/community-acquired-pneumonia

Those at risk

• Neurological dysphagia

• Stroke

• Copd

• Malignancy

• Renal disease

• Recent surgery or trauma

• Dementia

• Liver disease

• Enteral feeding

• Suppressed immune systems

• Surgery to treat cancer of mouth, throat or neck

Patients with Learning Disabilities deserve a healthy mouth too!

Function of saliva

• 1st Stage Of Digestion

• Lubricates

• Taste

• Antibacterial

• Regulates Oral Ph

• Facilitates Re-mineralization

Salivary glands

Parotid

Sublingual

Submandibular

The wonderful world of dentures…….

Types of dentures

Full and Partial Dentures Dentures with Implants

The wonderful world of dentures

• Toothpaste Not Recommended

• Manual Cleaning Is A Must

• To Be Cleaned With Liquid Soap Or Denture Cream Cleaner

• Nail Brush/Denture Brush

• Denture Soaking Solutions To Be Used As Per Instructions

• If Fungal Infection Present Consider Soaking In A Dilute Milton Solution, Each Evening For 10 Mins (plastic dentures-Corsodyl for Chrome)

• Treat Denture With Anti Fungal Treatment

• Remove dentures from person’s mouth

• Clean dentures in soapy water with nail/denture brush

• Disinfect denture by soaking in dilute Milton solution for 30 seconds

(if a metal denture use a Denutral cleaning solution)

• Dry denture

• Use an indelible pen to write residents initials near back of denture. Wait to dry

• Apply fine layer clear nail varnish

• Rinse with water

Denture Marking

Adapted from resources from RIS Healthcare and Salford Royal NHS foundation Trust. Reproduced with permission

Dental Implants…….treat them just like teeth!

Drooling

• “Saliva Beyond The Margin Of The Lips”

• Common In Lewy Bodies

• Prevalent In 70% Of Parkinson Sufferers

• 1 In 2 Patients With Motor Neuron Disease

• 1 In 5 Needs Continuous Saliva Elimination

Managing Drooling of Saliva.

• Medication- Hyoscine, Glycopyrronium bromide, Amitriptyline.

• Postural Changes/Support Collars.

• Suction, Training Required.

• Botox Or Radiation To Salivary Glands.

• Surgical Intervention To Remove Salivary Glands Is Sometimes Required.

Dry Mouth : Signs • Sticky, dry feeling in the mouth

• Trouble chewing, swallowing,

tasting, or speaking

• Burning feeling in the mouth

• Dry feeling in the throat

• Cracked lips and or corners of

the mouth.

• Dry, rough tongue

• Sore painful mouth and tongue

• Oral fungal infections

• Lips sticking to the teeth and

taste disturbance

• Bad breath ( odour )

Why is the mouth dry?

Diabetes

Chemotherapy.

Head & Neck Radiotherapy.

Medication – More Than 400 Drugs Can Cause A Dry Mouth-90% Of All Cases.

Oxygen.

Mouth Breathing.

Enteral Fed

A DRY MOUTH IS A CONDITION NOT A SIDE EFFECT

Managing a dry mouth

Artificial saliva and lubricants

Ice chips

Sugar free gum

Oral care

• LEVINE(1993) stated “THE SINGLE MOST IMPORTANT PLAQUE CONTROL METHOD IS TOOTHBRUSHING.”

• Brush natural teeth twice daily with a fluoride toothpaste.

• When Toothbrushes Are Old They Become Ineffective And Harbour Bacteria.

• They Will Need To Be Changed Every 2-3 Months.

• Sick People Are Advised To Change Their Toothbrush At The Beginning Of Illness And When They Are Better.

• Toothbrushes Should Be Changed Every Few Days If A Fungal Infection Is Present

Periodontal disease (bleeding gums)

• Bacteria in dental plaque

• Gum disease

• Swelling and bleeding gums

• Loose teeth

• Bleeding gums often frighten carers. The gums will bleed if they are unhealthy. The only way to make gums better is to brush bacteria away.

This hoto by Unknown Author is licensed under CC BY-SA

Toothbrushes

Looking after bleeding gums

• Gentle brushing where the teeth meet the gums

• They will bleed

• Bleeding eventually stop

• Consider that they May need a dental referral

TOOTHPASTES

• Some Toothpastes May Contain SLS (Sodium Lauryl Sulfate) Which

May Irritate Oral Mucosa.

• Sls Is Also What Makes Toothpastes Foam.

• Non Foaming Toothpastes Help To Reduce The Risk Of Aspiration

During Oral Care.

• Unflavoured Toothpastes For Patients With Sensitive Mucosa.

Mouth care for residents with

challenging behaviour

• Calm and kind approach, maintain eye

contact

• Choose location where resident most

comfortable (bedroom or bathroom)

• Ask family or carer for assistance

• Try different times of day

• Short bursts

• Familiar toothpaste/toothbrush

• Oral sensitivity, consider flavourless/non

foaming toothpaste

Adapted from resources from RIS Healthcare and Salford Royal NHS foundation Trust. Reproduced with permission

This Photo by Unknown Author is licensed under CC BY-SA-NC

Practical tips……..

• Distraction – Place

a familiar item in

their hands,

Toothbrush, towel,

or cushion

• Play familiar music

to distract or relax

If Resident refuses make a

record in notes but KEEP

TRYING

Quality of life

The end-of life deserves as much beauty, care, and respect as the beginning

Prevention is better than cure!

• 102 Year Old Lady

• Last Hours Of Life

• Mouth Smells

• Lips Stuck To Teeth

• Mouth Extremely Dry

• Crusty Plugs All Over Inside Of Mouth

In Conclusion

• Oral care assessment should be completed within 48hrs of admission

• The management of dry mouth should be included in the patients care plan

• Mouth care be carried out as often as necessary to maintain a clean mouth

• Prevent cracking lips – lubricating gel, if patient on oxygen apply a water based solution

• Assess the patient regularly, in terminal phase mouth may need moistening every 30 – 60mins