01243 710119                info@kohc.co.uk  

One of the recommendations we advise in our 'The Role of an Oral Champion' webinar,  is that we advise that care providers get feedback from service users [where appropriate]  or family, friends, advocates on the quality of care to include  mouth care support received.  

WHY WOULD GATHERING FEEDBACK BE A BENEFICIAL EXERCISE?

Because in CQCs new inspection methodology they have developed SIX categories of evidence which they will use when carrying out an assessment.  The first category is 'People's experiences of health and care services.  

CQC will be gathering evidence about people's experiences and explain that this is because they "value people's experiences as highly as other forms of information or data".   Of course you will want to ensure that the feedback sheds a positive light on the service and attend to anyone's concerns because CQC state that  "If we receive feedback that people have poor experiences of care we will always identify it as a concern. We will review further and gather more evidence". 

NEW.  SIX CATEGORIES OF EVIDENCE

1. People's experiences of health and care services

2. Feedback from staff and leaders

3. Feedback from partners

4. Observation

5. Processes

6. Outcomes

Maybe you've come across someone with a black tongue and wondered what the cause was and what should you do?

It looks sinister but it’s harmless and is usually related to ineffective shedding of the top surface of the tongue causing a build up of protein [keratin] making the tongue appear black, yellow, brown or green discoloration.

Certain lifestyle factors can increase the likelihood such as smoking alcohol, dehydration and poor oral hygiene.

MANAGEMENT
Practicing good oral hygiene is the best way to treat 'Black Hairy Tongue'. Gently brush the tongue with a soft toothbrush and a little toothpaste and you should notice that after time it will begin to improve in appearance. If the resident can tolerate it , you can use a tongue scraper.

When the mechanism of swallowing is not working efficiently saliva, food, drink may go down the wrong way causing the individual to splutter and choke which can be a scary experience for both carer and individual having mouthcare.

Compromised swallowing and poor oral health is related to higher rates of aspiration pneumonia (Langmore et al, 1998). Individuals are also more prone to decay due to the stagnation of food in the mouth and is further exacerbated when taking thicken fluids which contain starches and carbohydrates causing decay. Thus emphasizing how critical oral hygiene is.

Due to the levels of swallowing difficulties there is no single mouthcare management that can be applied to all individuals with dysphagia.

The main symptom of mouth ulcers is typically pain! Some ulcers can be so severe that they can interfere with eating causing problems with inadequate nutrition.

For people that suffer from recurrent mouth ulcers [Oral aphthous ulcers], the exact cause remains unclear.

Ulcers can also be caused by trauma such as loose, ill-fitting dentures rubbing underneath the denture so be sure to remove dentures when looking in the mouth with a torch pen. Another common finding is from broken or chipped tooth/teeth rubbing on the inner lip, cheek or tongue area or from accidently biting the tongue.
An ulcer/s may become more painful if they come into contact with an object such as a toothbrush, hard foods. Certain foods can aggravate them such as acidic, spicy and salty foods, alcohol and carbonated drinks.

Try this to help..
Rinsing with water after eating and/or warm baking soda dissolved in water
Antiseptic and local anaesthetic agents that can be bought over the counter

WHEN TO SEEK A DENTAL PROFESSIONAL
If it looks like the ulcer is caused from a rubbing denture or # filling or the ulcer does not appear to be healing after 10- 14 days.

Answer...

There are a range of oral swabs on the market, treated and untreated swabs in a variety of colours. The most common and recognised colours are pink and green. Sponge swabs are meant to moisten the oral cavity, help loosen sticky mucus secretions, food debris and thickened saliva. They are not effective at mechanically removing plaque from the teeth and gums and should not be a substitute for a toothbrush.

A small soft headed toothbrush is safe and effective for removing debris and plaque from all oral tissues, including the tongue, palate, cheeks and teeth.

The green sponges are supposed to have stronger adhesive but we do not encourage their use intra orally as all oral sponges pose a significant health risk. Sponge swabs are not to be soaked as it can loosen the glue and give a risk of choking if the sponge head becomes detached.

“In April 2012 oral sponge swabs of all colours were banned in Wales. The ban took into account a range of concerns raised by nurses and dental teams. The effective method for good oral hygiene is a small headed toothbrush and toothpaste” 1000 Lives Plus Faculty Lead for Dentistry

​

A clinical trial is about to start at the  University Hospital of Wales, Cardiff to establish whether-off the-shelf mouthwashes are effective at reducing the viral load in saliva of COVID-19 patients.

​

Results, published in the Journal of Medical Virology support the role of certain antiseptics, particularly cetylpyridinium chloride work by ‘deactivating’ or weakening the COVID-19 virus.

​

Whilst mouthwashes appear to kill the virus in a laboratory setting, scientists now need to find out if they work in patients.

​

A number of questions need to be answered like “ How long do the antimicrobial effects last?

So we’ll have to hold our breath and wait for the findings!

​

https://www.theolivepress.es/spain-news/2020/10/28/mouthwash-can-help-prevent-spread-of-coronavirus-say-doctors-in-spain/

https://www.dentistry.co.uk/2020/11/17/mouthwash-can-kill-coronavirus-seconds/

​

 Having direct contact with residents in long-term care facilities is inevitable, especially when helping people that are frail and vulnerable with personal care.

Scientists are still learning how COVID-19 is spreading and to what extent it may spread.

The virus is thought be be spread mainly via:

• Between people that are in close contact with on another

• Through respiratory droplets from an infected person via coughs or sneezing

• Transmitted indirectly, through the touching of contaminated surfaces

• Viral aerosolization in a confined space

• Contact with infected people who had no symptoms.

 The notion that viral particles can hang in the atmosphere ready to infect passersby, may seem scary.  However, airborne particles are “not believed to be a major driver of transmission,” It has been suggested the new coronavirus particles are unable to suspend in the air for an extended period of time as aerosol droplets quickly fall to the floor and surfaces but it must be emphasized that COIVD-19 may be suspended in the air as a fine mist after sneezing for example for up to 3hrs, hence it is essential that you sneeze into a tissue!!

Because carers have close contact to residents in an enclosed environment, there is an increased risk of COVID-19 infection, making oral healthcare all the more important.  What must be emphasized is that carers and healthcare workers need to have high levels of personal protection especially when dealing with personal care.

Q. Can an antibacterial mouthwash kill COVID-19?

Antibacterial mouthwashes are not effective at killing viruses, this includes Corsodyl mouthwash.  These are broad spectrum bacterial mouthwashes that are ineffective at killing COVID-19.  

Q. What can I use that will kill COVID-19 in the mouth?

A mouthwash that contains hydrogen peroxide because the virus is vulnerable to oxidation. 

There are currently two over-the-counter mouthwashes that the dental industry recommend

1.  Colgate Peroxyl mouthwash 

2.  Listerine Whitening Mouthrinse

These mouthwashes may provide a protective oropharyngeal hygiene measure for individuals at high risk of exposure to oral and respiratory pathogens.

 Prevention and Control recommendations

The dental profession in these recent weeks have been getting patients to rinse their mouth with Peroxyl mouthwash for 1 minute prior to treating a patient.

In addition to Personal Protective Equipment

• Use a mouthwash with 1% peroxide before tooth brushing is recommended for reducing potentially threatening oral microbes.

​

Mouth sponge swabs were a popular choice of product for care homes to use in palliative mouth care as they are inexpensive and did the job relatively well. Mopping up stringy saliva, removing secretions and aiding in hydration.

Products I have looked at and used in palliative mouth care are...

• Damp gauze (soaked in water or mouthwash)

• Soft small headed brush

• Mouth swabs (Moi Stiks alternative to glycerol swabs)

• MC3 sticks (rubber cone shaped sticks)

I can now add 360 degree toothbrushes to the list! Having had a number of hygienists, nurses and carers trial the brushes I can recommend them as a safe alternative to the sponge swabs. The bristles are designed for removing plaque and debris from the teeth BUT because the bristles are soft they can be used for cleaning the soft tissues of the oral cavity such as the palate, tongue and cheeks. They retain fluid and are idea for applying gel to the mouth.

Sold by Oralieve

Many residents residing in care homes require the support of others for their personal daily care. Mouth care is part of personal care although unfortunately ‘oral healthcare may be a low priority for many care homes’ (NICE) and although residents less abled are getting help with other aspects of personal care are not being assisted with mouth care.

For individuals to make behavioural changes, learn skills and continue to apply these over long periods of time to improve the health outcomes of the people who reside in care homes.  I believe that education and training initiatives giving carers reasoned actions is the way forward.

​

As a dental care professional I was interested to view the outcomes of carers that have had Oral Care Training in compared to those carers that have had no Oral Care Training.

​

Catherine Geraldine Waldron Thesis identified studies that that showed skill based interventions focused on oral hygiene skills or methods to teach these skills for a population with Learning Disabilities (although this review could additionally be applied to populations such as the elderly, people with dementia and conditions that require nursing).

Two studies examined  the effect of oral hygiene care training of carers on their oral hygiene care skills and behaviour as well as the behaviour of the people with LD for whom they care for:

​

Kissel 1983 Showed a general increase in carers use of training, a reduction in the level of assistance required and an upward trend in the level of self- initiated steps in the toothbrushing routine for the people with LD

​

Glassman 2006  reported an increase in the caregivers presence during the toothbrushing session, an increase in the seconds spent brushing by the people with ID and a very slight increase in the aptitiude of the person with LD in relation to toothbrushing.

Lower plaque levels

​

Lange 2000 study showed that carers that had training with accountability showed strong evidence of lower plaque levels  compared to the group of cares without accountability and comparing these to the carers who received no training the strength of evidence was still strong.

Behaviour change of carers after oral hygiene care training compared to those without training over a 4 weeks period.  The study reported strong evidence of positive differences in all five behaviours.

Oral Care has been put on the CQC list to prioritize mouth care. What better way to change caregivers behavior, attitude and skills necessary for  oral hygiene practices than through training. 

The result of  training carers may make them feel more motivated and incentivized to carry out oral hygiene care and may additionally result in the oral hygiene care becoming embedded in their routine.

​

The content and delivery of Oral Care Training and support of the trainer or training organization all play important roles in the success of carer led oral hygiene interventions.

Unfortunately as people advance with dementia they often become more resistant to mouth care. Admittedly, providing good oral care for residents that are uncooperative can be particularly challenging especially if people are aggressive.

Care staff are understandably less likely to want to approach and carry out mouth care in these cases.

If regular oral care is not carried out, a vicious circle of pain, discomfort and impact to the general health leading to an increased likelihood to resistance.



CLICK THE LINK TO FIND STRATEGIES AND TIPS YOU MAY FIND HELPFUL https://lnkd.in/gi2CAeP

1.Encouraging people to be as independent as possible

2.People refusing mouth care

3.If someone refuses to open

4.Biting the toothbrush

5.If someone show physical aggression

​

Plaque will stick to any hard surface and will therefore adhere to dentures just as they do on natural teeth, the regular cleaning of dentures is essential to the oral and general health of denture wearers.

1. BRUSHING DENTURE/S

Physically  cleaning dentures with a toothbrush or denture brush eliminates microbial plaque better than inactive methods, such as soaking.rather than inactive methods such as removing denture and soaking them.  

​

USING A DETERGENT

Using a  mild antibacterial soap or denture cleaning paste.  

2. ENCOURAGING RESIDENTS TO LEAVE THEIR DENTURE/S OUT AT NIGHT

Denture wearing during sleep was significantly associated with a higher risk of pneumonia

​

3. SOAKING DENTURE/S store in water or mouthwash. denture cleaning solution when required using manufacturers instructions (NOT overnight) DO NOT STORE DRY as this can cause an acyrlic denture to warp

​

4. DO NOT store denture cleaning tablets in residents' room ​​

VERDICT​

Provided that daily brushing of remaining natural teeth is carried out and tongue is brushed and not coated, Cleaning dentures with a brush, soap and water and storing in a named denture pot of cold water.

Soaking dentures in dentures in effervescent cleaning solution from time to time (as manufacturers instructions) should suffice.

​

Soaking in a denture cleanser solution after mechanical cleaning seems to be beneficial for people with denture stomatitis and the potential risk of pneumonia events in these groups of people.  

Denture Care Guidelines for FULL Denture/s by Oral Health Foundation (Aug 2018)

HAVE YOU EVER CONSIDERED THAT ALZHEIMERS COULD HAVE AN INFECTIOUS CAUSE! This alarming hypothesis is being supported by a growing number of scientific studies.

Whilst the evidence is not yet definitive Scientists say that they have a strong lead for a bacterial culprit and it comes from the mouth!

It has been concluded that people who had chronic inflammation of the gums for 10yrs + were 70% more likely to develop Alzheimers’ compared to those without.

Porphyromonas Gingivalis is the gram negative bacteria behind chronic gum disease which has been found in the brains of deceased Alzheimer’s patients.

Researchers found P. gingivalis in 90% of the brains of deceased people with Alzheimer’s, from more than 50 Alzheimers brain samples.

It is thought that the brain infection with P. gingivalis is an early event found in middle- aged people before cognitive decline.

It does not necessarily mean that everyone with gum disease will develop Alzheimer’s. But if YOU want to stay safe and potentially reduce your risk BRUSH AND FLOSS!!!.

 One of the reasons why mouth care is so critical in care homes is that elderly vulnerable adults are particularly at risk from developing respiratory diseases. Research has found a link between bacteria in the mouth and the development of pneumonia, a life-threatening condition and a leading killer in nursing homes.

If residents’ teeth are not brushed, plaque bacteria will form and mature on the teeth and dentures. Bacteria from the throat and mouth are breathed into the lungs to cause chest infections. Finding present evidence that there is a significant health risk to the elderly according to Dr N. Carter, Executive of the British Dental Health Foundation.

It is important for caregivers to pay attention to the mouth care of their residents so that they can help prevent them from possibly developing these health conditions.

We are holding a live webinar which will give a brief outline of the importance or oral health, why oral care has been put on the CQC list outlining the quality standard and more.

Working in partnership with Person Centred Software on bringing awareness about the importance of oral health. LIVE Webinar Tuesday 8th January 10am To register your interest visit www.kohc.co.uk

According to the Oral Health Foundation more than 7,800 people were diagnosed with mouth cancer in the UK last year and these numbers are predicted to rise in the coming years!

There are risk factors that can significantly increase one's risk.

* High alcohol intake and smoking have been linked to mouth cancer. These risk factors account for approximately two-thirds of all mouth cancer cases.

​

TO KEEP A HEALTHY MOUTH THROUGH LIFE.....

1. Take good mouth care regimes at home by removing plaque from all surfaces twice daily.

2. Eat a healthy diet, preferably one low in sugar, avoid smoking and excessive alcohol intake.

3. Have regular dental check-ups.

CHECK YOUR MOUTH FOR ANY ABNORMALITIES THAT HAVE BEEN PRESENT FOR 3 WEEKS OR MORE...

​

- Any lumps, swelling, red or white patches that cannot be wiped away.

- Experience numbness or feeling such as tingling sensations of the lips or in the mouth

- Sore throat, problems chewing or swallowing lasting more than 3 weeks

- If you notice any changes in your mouth seek a dentist or doctor. 

It is thought that 1 in 4 people have regular bad breath (halitosis). Some people do not notice that they have bad breath but other people WILL and will probably feel uncomfortable about saying anything The cause of bad breath is the breakdown of microorganisms in the mouth producing an unpleasant smelling gas, (VSCs ) Volatile Sulphur Compounds. So bad breath is caused by anaerobic bacteria – the main areas you’ll find these will be areas you’ve missed cleaning which tends to be in-between the teeth, gum margins and also the tongue. In actual fact when the bacterial load on a person’s tongue is reduced (by cleaning) there is usually an improvement in the quality of their breath. There are a number of foods that claim to be effective in controlling halitosis but green tea appears to be top of the list according to a study in Tokyo (2008) which showed green tea as being the most effective food in reducing VSC - (malodour strength) temporarily, when compared to other foods such as mints, chewing gum and parsley- seed oil. The reason for this it concluded was because green tea contains tea polyphenols which have antimicrobial and deodorant activities. So the next time someone approaches you with mouth odour, you might want to make them a cuppa green tea!​

THICK COATED TONGUE AND COATED PALATE IN THE PALLIATIVE CARE RESIDENT Ever wondered if you should be cleaning the palate and tongue? When the functions of the mouth is suppressed for example when someone is tube fed or has depressed consciousness, the ‘resting’ saliva begins to dominate mixing with the residue in the mouth to form a sticky paste that adheres to the soft tissues of the mouth and teeth. As the self cleansing function of the mouth are non or less active the tissue lining of the mouth is not being regenerated and replaced as should and instead the mucous remains on the palate and the tongue becomes coated. The bacteria flora of the tongue and palate contains bacteria that do not normally appear in a healthy mouth raising the risk of upper respiratory tract infections and thus aspiration pneumonia. Oral cleaning should at least include mechanical cleaning of the tongue and palate to remove pathogenic bacteria that can lead to aspiration pneumonia. The mouth is an organ that responds promptly to proper care becoming moist and healthy in colour as soon as it is cared for.

Caregivers that are reading this will have noticed the amount of residents they assist with tooth brushing that present with broken teeth. Have you ever wondered why? For most, the reason being is that these teeth are so decayed they have broken. It is not uncommon for sharp broken teeth to cause sore ulcers from rubbing on the soft part of the mouth. The one simple piece of advice to help strengthen the teeth and help prevent decayed broken teeth is to avoid rinsing after brushing for both the dependent and independent person. Why? Most toothpastes contain fluoride.  Fluoride helps strengthen the enamel making it more resistant to tooth decay. It remineralizes the enamel - meaning that the fluoride gets absorbed onto the surface of the tooth where decay has occurred. (minerals are deposited back onto tooth areas where mineral content has been lost). It is thought that most people brush their teeth for less than 1 minute, this is likely to be even less for people that are being assisted with tooth brushing, which doesn’t give fluoride very much time to work on the teeth. Therefore, leaving the remains of the fluoride toothpaste in the mouth, will benefit the teeth in helping to prevent tooth decay.

A dental hygienist colleague saw this on the M40.  Says it all.  It's not just a theory, there's a link between poor oral health and systemic disease.

One of the most frequent questions I get asked when giving oral care training is “what is the best toothpaste?” and it’s hardly surprising people confused when there are so many toothpastes to choose from. Toothpaste is an aid in mechanical brushing to remove plaque bacteria - a sticky biofilm which builds up along the margins of the teeth.   Some residents will have been prescribed a toothpaste from their dentist, this  contains a higher % fluoride which helps aid in protecting and strengthening the enamel.  Only 1/2 a pea size amount is needed on the toothbrush and try to resist getting the resident to rinse out. If buying a toothpaste from the superstore for your residents, I would suggest that you avoid any  WHITENING toothpastes.  These toothpastes attempt to break down superficial stain and dehydrate enamel causing the teeth to appear temporarily lighter but for the elderly this has a drying effect on the mouth. And as many elderly people that suffer from a dry mouth it would be advisable to look for a mild, SLS free (non- foaming) toothpaste such as Oralieve, Sensodyne Daily Care Original, Biotene toothpaste.

I WANTED TO KNOW IF THERE WAS ANY BENEFIT TO USING PINEAPPLE JUICE IN PALLIATIVE/END OF LIFE ORAL CARE?

Having attended numerous care homes I was surprised to have some carers and nurses tell me that they use pineapple juice for palliative/end of life oral care. I couldn't think what the benefit would be for using a food with such a high acidity level as this would cause dry mouth as well as causing damage to the teeth.

 I could not find any proper clinical trials that had been conducted supporting its use.

There was one paper he found by Cheng KK, Molassiotis A, Chang AM et al (2001) Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in paediatric cancer patients. (European Journal of Cancer 37(6):2056-2063)

 This paper mentions that pineapple juice, although used in some quarters can cause irritation in patients with ulceration of the mouth and also damages the teeth.

Pineapple juice contains an enzyme called bromelain which acts as a meat tenderiser. The pH is between 3.2-4 and it is also a juice low in antioxidants in relation to other fruit – surprisingly apples have one of the highest levels of antioxidants. At one time some cancer patients were advising the use of pineapples because of the antioxidants so this helps refute this argument. 

All pineapple juice did was stimulate saliva if there is some function left ( but same issues as with lemon and glycerine mouth swabs) and it helps break down thick stringy saliva and makes this easier to remove. Regular use of water based gels helps with this as does the use of steam inhalation and saline nebulisers or saline or sodium bicarboanate mouthwashes (later used in short term only)-

I never advise pineapple juice – in fact I positively discourage it.

The NICE Quality Standards 'Oral health in care homes' were published last week

In summary it expects:

1.  Oral Health Assessment

Adults who move into a care home have their mouth care needs assessed on admission (within 1 week)

2. Mouth Care Plans

Adults living in care homes have their mouth care needs recorded in their personal care plan.

3. Implementing Daily Oral Care

Adults living in care homes are supported to clean their teeth twice a day and to carry out daily care for their dentures.

TRAINING is advised to "ensure that care staff are trained to understand mouth care needs and carry out the assessment, and that they are aware of signs of dental ill health, for example tooth decay, abscesses, dry mouth and gum disease."

Quality statements https://www.nice.org.uk/guidance/QS151

For more information, help or just advice on:

Oral healthcare matters, plans, policies, how to implement an oral care service, who can provide oral care training, how and who to refer to in a dental emergency etc

Contact Jane & Sarah at info@oralhm.co.uk

Care homes are seeing an increase in the number of people being admitted with more of their own teeth as people are keeping their teeth for longer.

The elderly in care homes are encouraged to remain independent for as long as possible but as the elderly become less able to brush their teeth adequately they become more reliant on care staff for daily oral care. With a general lack of availability to dental care services, support and training it is no wonder that oral care in care homes has been recently criticized for not being seen to prioritize this area of personal care.  

Providing an oral healthcare scheme to provide a simple oral care service in care homes and training is so needed as the staff need support, advice and help with oral hygiene procedures. NICE Guidance was published in July ‘Oral health for adults in care homes’ which recommends guidance on oral care pathways to care managers to implement in their care homes although training by dental professionals seems to be the missing link at present. 

The NICE Guidelines will help raise the level of oral awareness in care homes enabling that oral care needs to be addressed and documented. Some community dental services suggest the care homes nominate a staff member as an ‘oral champion’. I am hopeful that this will help improve the level or oral care throughout a care home as this role will ensure that oral care procedures have been carried out. NICE Guidelines (NG48)

Health

Plaque is largely thought of as affecting the dentition but it is important to highlight the sense of wellbeing a clean mouth has and the effects poor oral health has on the body. Perhaps the most important link is between dental plaque and aspiration pneumonia, a life threatening condition which is caused when bacteria and debris from the mouth and throat is inhaled to cause an infection in the lungs. It is of utmost importance to reduce as much plaque and debris from the mouth including dentures on a daily basis to lower the incidence of such cases.

Challenging

Residents with dementia are more likely to be challenging in oral care procedures and as this group is expected to rise significantly in the future my concern is that oral care will fall further. For staff that find carrying out daily oral care procedures unpleasant, having to deal with people that resist or reject brushing can only serve to exacerbate those feelings.

Restoring and extracting teeth on frail elderly people is certainly not ideal and makes sense that plaque control and education are key matters.

A set of simple guidelines was created by researchers after reviewing 14 papers relating to oral health among patients with Parkinson’s Disease.
The objective of the review [March 2021] was to organize a list of evidence-based recommendations for the oral care of patients with PD to help address general dental care, as people with PD have notably reduced quality of oral hygiene, and exhibited a high prevalence of mostly preventable oral conditions, according to study findings published in Neurology and Therapy.

RECOMMENDATION:
Toothbrushing should be performed alternating the toothbrush from one hand to the other since rigidity and tremor may be more disabling in one limb as PD progresses. The patient should therefore learn to use both hands for mouthcare.


Reference
Evidence-Based Recommendations for the Oral Health of Patients with Parkinson’s Disease, Ana L. C. Martimbianco, March 2021

​

https://link.springer.com/article/10.1007/s40120-021-00237-4

A popular question asked by caregivers is ...should dentures be stored in water or dry? It's a question that admittedly I have become confused about as some dental technicians say that leaving dentures out to dry can distort them.

The very lovely Dr Mark Wotherspoon [dentist] from Dr Marks Hygienie dental cleaning products got in touch to let me know of a paper that was published recently [Aug 2020] which reviewed a number of studies comparing dry vs water immersion. It concluded that storing dentures dry was better as it destroys C.albicans on the denture and any movement of the denture was not clinically significant

In 85-90% of cases halitosis {bad breath} originates from the mouth caused by entrapped food particles usually in-between the teeth and bacterial reservoirs such as untreated cavities, advanced gum disease, back of the tongue, over wearing dentures at night… basically anywhere bacteria is left to harbour. If not removed it will degrade into volatile sulfur compounds [smelly breath]

But what if you have cleaned all the teeth surfaces and tongue yet the malodour is still there. If toothbrushing doesn’t remedy malodour the cause maybe something else. You may suffer from a dry mouth? The absence of saliva results in an increased Gram-negative microbial load, which increases malodor and is a contributor to your morning breath!

In 10-15% of cases halitosis comes from other factors called Extraoral halitosis

1. NON-BLOOD BORNE HALITOSIS - from the nose and the respiratory tract
2. BLOOD-BOURNE HALITOSIS - underlying health conditions which lead to chemical changes in your bloodstream or changes to bacteria levels in your body.

ADVICE
- Remove those bugs mechanically with a toothbrush and paste
- Clean in-between with floss or interdental brushes
- And as an adjunct use a mouthwash – Reminder, it won’t remove plaque!

If in doubt seek a dental professional!

The COVID‐19 pandemic has, within a rather short period, amplified and intensified the oral health challenges in care homes.
As essential oral hygiene practices become recognised more widely as a priority area, I would like to share with you the Public Health England Guidance 'Mouthcare for patients with COIVD-19 or suspected COVID-19' which ia a guide for staff attending to patients oral health in hospital but these guidelines can be appoled in care homes.
 

• do not use an electric toothbrush as this may cause droplets and splash

•  

• when performing mouth care service users are more likely to cough, be gentle, stand to the side or behind them, take breaks to allow the patient to rest and swallow

​

Document downloaded HERE

The revised Framework for Enhanced Health in Care Homes was published on 31st March 2020.
The long term plan is to avoid long stays in hospitals by being proactive by getting help early on with social care services

ORAL HEALTH CARE has been added to the Care element 1. Enhanced Primary Care Support.

The paper highlights the importance of good oral health for general health and wellbeing

That poor oral health can lead to:
 

• Pain - Mood behaviour

• Chewing difficulties – limited food choices affecting nutrition

It acknowledges that care staff may find difficulties at times with people more challenging such as people with advanced dementia

Outlining Best Practice:
1. Oral Health Assessments to be carried out at initial admission, establish oral health needs and support planning process

2. Oral Health Policy should be put in place with an oral champion to oversee that policy procedures have been carried out.

3. Ensure that the teeth have been brushed by enquiring and assisting where necessary. Residents should have access to routine dental checks and specialist dental professionals as appropriate.

4. Employed care staff should have training in oral health to include knowledge & skills to carry out oral health assessments and daily mouth care for individuals.

One of the most common dental/oral complaints in care homes is loose dentures. There are a number of reasons that can cause denture to become loose such as weight loss and facial muscle tone, bone resorption (gum recession)

Wearing loose dentures can cause sores (ulcers) in the mouth due to the denture/s rubbing on the gum and thereafter making eating difficult.

A denture adhesive is an instant helping hand to give better retention and stability as well as helping to improve self-esteem and comfort.

If you are a carer reading this you no doubt have experienced removing or attempting to remove denture adhesive from a resident’s mouth….it can be a messy task!
Quite often too much fixative is applied to the denture, only a small amount needs to be applied to a dry denture once a day.

From personal experience A DENTURE ADHESIVE of choice is ....“POLYGRIP”

BECAUSE…. it is less messy and easier to remove from the mouth than other products on the market.

For the latest denture adhesive guidelines (The Oral Health Foundation) 

TIP
The best tools I have found to remove denture adhesive is
Damp gauze or 360 degree toothbrush

Polygrip samples are given after a training session

Saliva is especially important to denture wearers as it helps retain the denture, the moisture creates a suction between the denture and gum tissue needed to help dentures adhere to the gums for a better fit.

TIP
Look to see if the resident suffers from a dry mouth. If this is the case apply an oral moisturising gel under the denture.

This lubricant will help to prevent irritation and abrasion that can cause sore spots under the denture.
 

The way in which frailty is defined and measured may vary but in general - people in advanced age with declining health leads to adverse health outcomes including dependency which can impact their oral health.

Fried’s phenotype model of frailty includes the following:

• weight loss

• exhaustion

• low energy

• slow gait speed

• weakness with hand grip and strength

Hand grip and strength is required for tooth brushing and therefore ensuring that a person can brush his or her teeth independently or requires assistance is paramount in ensuring that plaque bacteria is removed from the teeth surfaces adequately.

Ensure that on your Oral Assessment Form there is an area that states if a person is able to brush their teeth independently or whether they require assistance.

End of life mouth care management is about keeping a person comfortable, clean and hydrated.

​

Keeping the mouth clean and moist by removal of plaque and debris to reduce halitosis and prevent the becoming coated as well as keeping the lips clean and moist with water-base gel.

The reason for this post is that, to make carers and nurses aware that hydrating the mouth with a persons' favourite tipple such as Bayley's, Sherry might sound like a nice thing to do but this should be avoided as alcohol has a drying effect on the mouth and will further dehydrate the oral mucosa.

ALSO avoid pineapple as this will over exacerbate the saliva secretion and again cause the mouth to dehydrate.

Keeping the mouth hydrated consider:

cold unsweetened drinks,

sips or sprays of cold water ice cubes/crushed ice lollies.

For revised NICE Palliative care - oral Oct 2018

​https://cks.nice.org.uk/palliative-care-oral

​

Wearing dentures continually, and especially at night when salivary flow naturally diminishes, often results in a condition called denture stomatitis, the palate becomes reddened, inflamed and infected with yeast. If left unchecked can become serious and therefore guidelines for optimal denture care are important.

Underneath surfaces of dentures in particular can become breeding grounds for oral bacteria and fungi, which can cause odors, irritation and disease. This can be treated by leaving the dentures out at night, and cleaning them meticulously.

​

Aspiration Pneumonia

There is evidence that denture wearing during sleep increases the risk of aspiration pneumonia, a potentially life-threatening condition in the very elderly.

Bacterial plaque will stick to any hard surface and therefore will adhere to dentures as well as teeth. If dentures and teeth are not meticulously cleaned pneumonia-causing bacteria from the these surfaces get inhaled from the mouth into the lungs to cause the elderly to become very poorly.

Study

A study by linuma et al. in 2015 involving 542 randomly selected elderly people in nursing homes who slept with their dentures in were 2.3 times more likely to die or be hospitalized from pneumonia compared to those who removed their dentures.

Conclusion

We may conclude that any intervention that can eliminate or reduce bacterial colonization of dentures should be encouraged therefore denture cleaning is vital for the overall health.

Giving the oral tissues a chance to rest, recover and receive exposure to the antibacterial agents present in saliva. Removing dentures for at least five to six hours a day is ideal.

To change denture wearers behaviour it maybe an effective idea to address and approach the knowledge. A possible reason is fear of denture loss in the case of an expected event?

Oral health is often neglected at the end of life as mouth hygiene practices may be forgotten or eliminated, this can contribute to halitosis and can impact on contact with friends and family members avoiding loved one due to bad breath and worsening a person’s isolation. As the body slows down towards the end of life so does the intake of food and /or fluids. The best way to make a person feel better, in addition to toothbrushing is to provide frequent fluids while they are able to drink and when that is no longer possible, ensure that the mouth is kept moist. Towards the end of life people are more vulnerable to oral problems such as thrush no matter how well their mouth is cared for, therefore it is IMPORTANT to check the mouth for any sores or coating that could indicate thrush. ASSESS. Refer to NICE Guidelines (revised Oct 2018) Palliative care - oral.

​

I was given an Oral Health Policy to review for a hospice, in the policy it had …. “ provide minimal intervention – frequent mouth care can be distressing and obtrusive for patients that are unconscious and settled.”

It is my understanding that unconscious patients require mouth care as often as every 2 hrs and 4-6 hourly care is recommended for patients that are palliative care. This may not necessarily be brushing teeth each time but to ensure that the mouth is hydrated as unconscious pt’s often breathe through the mouth and removing secretions that can lead to infection.

The frequency of oral care reduces the potential for infection, inflammation and promotes comfort.

The oral microflora in a critically ill person changes from predominantly aerobic oral organisms in a healthy person to primarily gram negative organisms within 48hr of a person becoming critically ill. This represents a more virulent flora that has the potential to develop oral infections and respiratory tract infections which can further impact on their condition.

​

There is a Review of the current Palliative Oral Care Guidelines by Alina Grossman to inform best practice in this state.

What is the best toothpaste to use for someone with AUTISM?

Many people on the autism spectrum sense the world differently to other people, they have difficulty processing everyday sensory information.

Some of the most common problems autistic individuals experience is their hyper or hypo sensitivity to stimuli such as sight, sound, taste and smell.

Mouth care can be particularly challenging as it is a sensory experience causing some people with autism to be resistant to the bristles and /or texture of the toothpaste, ie foaming as well as the flavour.

Due to the invasive nature of toothbrushing, it can trigger resistance and behaviour issues such as temper tantrums. Brushing can be impossible sometimes but confronted with the fear of cavities we keep persevering to brush and finding the right toothpaste.

RECOMMENDED TOOTHPASTE

There are unflavoured toothpaste specifically formulated for people sensitive to strong flavours.

I would be inclined to select a toothpaste that is mild in flavour or flavourless and is Lauryl Sulphate free as the texture of the foaming can trigger sensory issues.

Some examples are:

• Oralnurse toothpaste (unflavoured)

• Kingfisher toothpaste

• Oralieve

It is not necessary to throw your toothbrush away or disinfect it if you are sick as you are unlikely to re-infect yourself.

Viruses can live on a moist surface for up to 72 hours, therefore, you should allow your toothbrush to completely dry out before reusing it as germs won’t survive – Store your brush in an upright position by placing it in a holder.

It would be a good idea to change your toothbrush once you are well again.

If you have vomited avoid brushing your teeth straight away, instead rinse your mouth with water or fluoride mouthwash as stomach acid will soften the enamel for approximately 30mins after being sick. The bristles could scrub off a microscopic layer of enamel.

Most care homes are aware that mouth sponge swabs have been banned in Wales and are to be used with extreme caution in England. (Medical Device Alert www.gov.uk/drug-device-alerts) Having noticed that many care homes are using glycerine swabs in replacement to the sponge swabs I thought that I would mention that these are NOT something we recommend as they are acidic and will consequently have a drying effect on the mouth. There are however swabsticks which have a neutral PH and will give better relief. ALTERNATIVES to sponge swabs * Moi-Stik (neutral PH) * Damp Gauze soaked in water * MC3 Mouth Cleanser My personal preference is damp gauze as it is ideal for removing debris, plaque and dried mucus secretions from the lips and mouth. Please feel free to email me with any questions. For more information please visit https://www.kohc.co.uk/news

Firstly could I just point out that if you read the instructions on a denture cleaning product, it states that dentures should be soaked for 20minutes in other words NOT overnight. If the dentures are soaked overnight overtime the solution bleaches the acrylic making the material porous and brittle and more likely to fracture and break in time. Dental technicians advise using a toothbrush, water and mild soap – obviously rinse thoroughly before inserting into the mouth!! and soak overnight in water. Secondly and most importantly it is advised that IF denture cleaning solution is used – It should NOT be stored in a resident’s room due to the risk of a resident ingesting the solution or tablet. I know of a care home manager who was recently picked up at a CQC inspection about the storage of denture cleaning tablets, they were informed that they must not be kept in the resident’s room, and IF used, they should be in a sluice or other room, away from a resident. This was instigated after an incident whereby a resident ingested a denture cleaning tablet in a care home and very sadly died

As we grow older our sense of smell and taste changes. We are born with approximately 9,000 taste buds which  are regularly regenerated until after 50 when regeneration and taste is reduced. The basic taste sensations are sweet, sour, salty and bitter which after the age of 60 we may begin to lose the ability to distinguish.  Our sense of smell is thought to diminish after the age of 70 and so the loss of taste is exacerbated. This may not be as important as the resulting effects an older person’s nutritional balance as for many losing the senses of taste and smell means diminished appetites. Because saliva production also diminishes with age, the elderly may also experience dry mouth and have difficulty swallowing. For an older person this can have a significant impact on the quality of life when eating becomes more of a chore than an enjoyment possibly leading to eight loss, malnutrition, impaired immunity and deterioration in medical conditions. Wanting a higher salt and sugar intake in food can aggravate health hazardous conditions. From a dental aspect the consequence of a higher sugar intake is a result of many broken and decayed teeth. If a resident has been prescribed a higher concentration fluoride toothpaste USE IT!

In care homes pneumonia is the second most common infection after urinary tract infection, and the leading cause of death among the elderly in long term care. With 30% of those who die of pneumonia are diagnosed with aspiration pneumonia. Aspiration pneumonia -a life-threatening and largely preventable disease where foreign matter is inhaled into the lungs to cause an infection. As elderly residents become more dependent on staff for their daily oral care it is important that staff carry out adequate brushing not only to prevent dental disease such as decay, gum disease and tooth loss but to primarily look to lower the bacteria level in the mouth. LITIGATION If an aspiration pneumonia event results in wrongful death of a client, a nursing home could potentially be made accountable and a case could be considered which has led to some law firms in the US advertising they specialise in defending families impacted by aspiration pneumonia. The mouth deserves greater recognition so that less people suffer from aspiration pneumonia through proper oral care in the future.

DID YOU KNOW.....One of the reasons why Mouth Care been put on the CQC inspection list... To prevent incidence of ASPIRATION PNEUMONIA!  What is ASPIRATION PNEUMONIA?  A  life threatening condition where food debris and mature plaque get inhaled into the lungs to cause an infection.  Pneumonia is one of the most common nursing home infections with a high case fatality rate. "Evidence suggests that nurses have little knowledge of the link between poor oral health, dysphagia and pneumonia, so further mouth care training is recommended".  NICE comments In fact, victims of aspiration pneumonia have a mortality rate three times higher than non-victims in nursing homes.  In many cases, especially in nursing homes and assisted living facilities, the disease could have been prevented with quality mouthcare and mindfulness of the situation by caregivers and staff. It's why mouth care needs to be put on your training list. Mouth Care training by Dental Care Professionals.  www.kohc.co.uk 

Having an Oral Care Policy for your care home is Best Practice and to be honest is something you really should think about putting in place if you haven't already.   It gives easy access to you and for others to find details about how to access the community dental service with regards to referral forms and local dentist details, emergency contact numbers should a resident be in need of a dental services.  Looking up and enquring about this information up can be considerably time consuming.   My personal advice to a care home would to befriend your local dentist!!!!  An Oral Health Policy template is your pathway to accessing dental care.  Having a policy in place  will be looked upon favourably.  The other things to consider including in an oral care policy is: - What your carers should do if a resident refuses daily oral care  - Oral care regime,  - Oral health assessments  - Oral care training For anyone that would like an editable Oral Care Policy please feel free to contact me  on info@kohc.co.uk and I will gladly forward one onto you

Good oral health makes a real difference to us all when it comes to comfort and well-being, appearance and confidence, self esteem and social acceptance.

People with learning disabilities often have greater and more complex health needs and yet this is often unrecognised and these needs remain unmet. Evidence supports the fact that people with learning disabilities have poorer oral health compared to the general population and it can be so easy to unintentionally neglect the mouth as once the mouth is closed you no longer see the problems.

Prevention of dental disease is the way forward and the approach adopted by Dental Care Professionals. However preventative advice can be difficult to action due to common barriers of communication experienced with people with learning disabilities. Reducing sugar frequency and modifying the diet, in accordance with healthy eating policies, can make huge differences, alongside educating individuals and carers on the importance of regular oral health assessments and recommended oral hygiene regimes; including the use of fluoride toothpastes. But what is essentially important is that we consider every individual and ensure we approach the matter of oral care with dignity and respect. Empowering those we care for by involving them with their own oral health care contributes not only to building bonds and gaining trust but to making real improvements in oral health. Every person is unique and so tailoring oral care regimes for every individual can be challenging which is why it is imperative that carers with responsibility have a good understanding of the preventive measures available, which are appropriate, and which should be adopted. Dental Care Professionals can help support the care sector by contributing to the education of carers at all levels because teamwork is really what makes a system work and people with learning disabilities are often so reliant on such healthcare systems. 

Care homes will need to have an oral care policy in place which is designed to be shown oral care policy to be providing residents with support to access dental services.

The NICE Guidance Oral health for adults in care homes standards & quality draft will be finalized in June and therefore care managers need to look at establishing their own oral care policy.

Care managers should be thinking about having care home policies that set out plans and actions to promote and protect residents oral health.

The basic elements of what should be included in an oral care policy include:

• Information about local general dental services and emergency or out-of-hours dental treatment. You need to do your homework to find out about the community dental services, including special care dentistry teams in your area.

• If you have an oral health promotion service document the details

• Indicate your oral health assessment of newly admitted residents' oral health and referral to dental practitioners specifying the referral process.

• Plans for caring for residents' oral health.

• Daily mouth care and use of products and who supplies them.

• What happens if a resident refuses oral health care (Look at the Mental Capacity Act and policies on refusal of care).

• Set out your duty of care and access to dental care services.

• Mouth care regimes should be included and a review timeline stated inline with local practice.