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Open W

ide: Better oral care for adults with additional care needs

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Open WideA guide for trainers

Better oral care for adults with additional care needs

V4_06.03.18_6397

Published by NHS Health Scotland

1 South Gyle Crescent Edinburgh EH12 9EB

© NHS Health Scotland 2018

All rights reserved. Material contained in this publication may not be reproduced in whole or part without prior permission of NHS Health Scotland (or other copyright owners). While every effort is made to ensure that the information given here is accurate, no legal responsibility is accepted for any errors, omissions or misleading statements.

NHS Health Scotland is a WHO Collaborating Centre for Health Promotion and Public Health Development.

This resource may also be made available on request in the following formats:

0131 314 5300

nhs.healthscotland-alternativeformats@nhs.net

ForewordMaximising our oral health improvement effort for priority groups, including adults with additional care needs, is a key feature of the Oral Health Improvement Plan (2018). The plan states that we must ‘develop common educational opportunities and partnership working wherever possible’. In Scotland we already have well established oral health improvement programmes for children and dependent older people. It is important that people can move seamlessly between these programmes as they age.

Cleaning a person’s mouth, teeth and dentures can be one of the most challenging aspects of providing personal care for a family member or carer to undertake. Unfortunately the effects of ineffective oral care include tooth decay and gum disease which can be painful and distressing. Ineffective oral care affects an individual’s ability to communicate and eat. It also affects their overall general health and wellbeing. Indeed, without oral health a person cannot be truly healthy.

While significant progress has been made in terms of oral health improvement for much of the Scottish population, poor oral health still impacts greatly on vulnerable groups in the population, highlighting significant health inequality. Keys to Life (2013), a Scottish Government report, recognised that oral health is poor in people with a learning disability and that responding to an individual’s complex oral health needs can be difficult. Some adults within this group cannot perform their own oral care effectively and rely on others for help with self-care. The provision of additional support is often dependent on carers’ knowledge of, and attitude towards, oral care.

Open Wide has been developed from pilot work to improve the oral health of adults with learning disabilities in East Ayrshire but now covers all those who need help with oral care due to physical, cognitive or medical difficulties. We recognise that this is a diverse group, but we want to be inclusive not exclusive, so our definition of ‘additional care needs’ is broad.

It is the responsibility of everyone involved in supporting people in their health and wellbeing to be aware that oral health plays an important role within their work. Open Wide is a training pack for delivering training on oral health improvement, as well as a reference manual for those who provide oral care for adults with additional care needs. I recommend it to you as an important tool for influencing daily practice.

Tom Ferris Chief Dental Officer (Interim)

AcknowledgementsThis guide for trainers, which is published by NHS Health Scotland on behalf of the Adults with Additional Care Needs Oral Health Improvement Group, has been prepared by the Open Wide writing subgroup, whose membership is as follows:

Maura Edwards, NHS Ayrshire & Arran

Trish Gray, NHS Education for Scotland

Brenda Hendren, NHS Lanarkshire

Anne Moore, NHS Lanarkshire

Elizabeth Peat, NHS Highland

Fiona Rodger, NHS Lothian

Sarah Urquhart, NHS Health Scotland

Grateful thanks are due to:

• The Oral Health Improvement Team in NHS Ayrshire & Arran and the East Ayrshire Dental Health Action Group who developed the original Open Wide pilot.

• NHS Education for Scotland

• The Care Inspectorate

• NHS Health Scotland

• Anne Moore, M. Petrina Sweeney and staff in NHS Ayrshire & Arran who provided photographic images for the guide.

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Contents Foreword 1

Acknowledgments 2

Introduction 4

Unit 1: Core oral health knowledge

What is oral health? 11A healthy mouth 12Oral health and adults with additional care needs 16Oral diseases and conditions 16Diet and oral health 21Other factors which may have an impact on oral health 25Mouth cancer 29

Unit 2: Practical daily oral care

Cleaning teeth and soft tissues 33Steps for cleaning natural teeth, soft tissues and dentures 38Practical tips for those who are tube fed 42Possible complications 43Palliative care 45Additional products and aids 45Overcoming specific barriers in oral care 47

Unit 3: Oral health documentation

Why oral health documentation should be completed 53Oral health risk assessments 54Oral care plans 56Daily oral care records 58Three steps to ensure daily oral care is tailored to each individual 60Dental referrals 61

Glossary and appendicesAppendix 1 – DisDAT 68Appendix 2 – Activities for training 76Appendix 3 – Case studies 81Useful contacts, resources and information 89

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Introduction

IntroductionIn 2012 the Scottish Government published the National Oral Health Improvement Strategy for Priority Groups. These groups include people with additional care needs, frail older people and people who are experiencing homelessness. The strategy identified the need to develop new oral health promotion packages, along with dedicated services, for people with additional care needs.

A local oral health needs assessment in one area of Scotland found that the oral health of adults with additional care needs can be dependent on carers’ knowledge of, and attitude towards, oral care. It also found that support workers do not always receive training in oral care and diet.

Adults with additional care needs

Most people within this group who need help with their oral care fall into one of two categories.

1 People with physical impairments, some examples of which are:

• people with conditions affecting swallowing, like advanced multiple sclerosis (MS) – this would include percutaneous endoscopic gastronomy (PEG)-fed patients

• people with arthritic-type conditions

• post-stroke patients

• people with cerebral palsy

• people with sensory impairments.

2 People with cognitive impairments, some examples of which are:

• people with learning disabilities (mild to profound)

• people with cognitive impairment due to acquired brain injury (ABI)

• people with cognitive impairment from medical causes (such as a stroke or Huntington’s disease)

• people with dementia.

These lists and examples are not exhaustive by any means, but it may be helpful to consider whether the person you are caring for is in one of these categories. Irrespective of the cause and the impairment, the same principles apply to the delivery of good daily oral care.

This guide for trainers was initially developed to train carers who look after adults aged between 16 and 64 who have additional care needs and live in a care home. However, we recognise that this is only one potential setting. Some

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Introduction

individuals may live in their own homes and be cared for by family members, while others might live in supported accommodation with input from carers. Regardless of the setting, the principles of oral care remain the same.

The common risk factor approach

There are many factors that influence both good oral and good general health – oral health does not stand alone. This training manual uses a common risk factor approach. We encourage the use of this approach in all training. It recognises that many common chronic diseases and conditions, such as tooth decay, periodontal (gum) disease, obesity, heart disease, stroke, cancers and diabetes, share a set of common risk factors (see Figure 1 below).

Figure 1: Common risk factors for common chronic diseases and conditions.Adapted from Sheiham A & Watt RG. The Common Risk Factor Approach: a rational basis for promoting oral health. Community Dentistry and Oral Epidemiology. 2000; 28: 399–406.

Obesity

Cancers

Heart disease

Respiratory disease

Tooth decay

Periodontal disease

Trauma

Diet Smoking

Stress Alcohol

Control/ autonomy Exercise

Hygiene Injuries

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Introduction

By adopting the common risk factor approach, it is possible to improve oral health and tackle things like poor diet, smoking and alcohol use which are common to many chronic conditions. The potential benefits of such an approach are far greater than the benefits of isolated interventions. This approach is advocated at a global level in the World Health Organization strategy for oral disease prevention.*

Aims and objectives of training

Training does not make the trainee an expert. However, by the end of the training programme, carers of people with additional care needs should be able to:

• explain why good oral health is important

• recognise the role of diet and other factors in contributing to poor oral health

• demonstrate effective communication strategies in supporting people with oral care, particularly when they may be showing signs of distress

• identify the importance of the various oral care forms and be able to carry out an oral health risk assessment for people with additional care needs

• differentiate between the need for non-urgent and urgent dental referral

• recognise that toothbrushing, diet and dental visits are the main steps towards good oral health, and that these may need some adaptation for people with additional care needs

• know when and how to report any oral health concerns.

In the longer term, trainees should be able to:

• confidently carry out day-to-day oral care for people with additional care needs who require assistance.

The training has the following units:

Unit 1: Core oral health knowledge

This looks at the causes of tooth decay and gum disease, and the effect of diet and other factors on oral health.

Unit 2: Practical daily oral care

This section offers advice on oral care, including toothbrushing, oral hygiene aids and denture care. It is recognised and appreciated that it can be challenging for carers to carry out oral care for adults with additional care needs, so this section gives some possible ways to overcome difficulties.

* Bulletin of the World Health Organization, World Health Organization; 2005.

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Introduction

Unit 3: Oral health documentation

This section contains examples and instructions on how to complete the following documents:

• Oral health risk assessment

• Oral care plan

• Daily oral care record.

This section also explains when dental referrals should be made and who these should be made to.

Glossary and appendices

These include materials for use during training, such as activities and case studies.

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Introduction

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Unit 1: Core oral health knowledge

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Unit 1

Unit 1: Core oral health knowledgeKey points• Good oral health will contribute positively to overall health and wellbeing.

This unit will cover• The importance of good oral health: to enable people to eat, communicate

and socialise.

• What a healthy mouth is, and the causes of poor oral health, including prevention and treatment strategies.

• The importance of diet in maintaining good oral health.

What is oral health?

Definition of oral healthOral health can be defined as:

‘A state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.’ (World Oral Health Report, World Health Organization, 2003)

The term ‘oral health’ refers to the whole mouth, including:

• teeth

• gums

• hard and soft palate

• soft mucosal lining of the mouth and throat

• tongue

• lips

• salivary glands

• chewing muscles

• upper and lower jaws.

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Why is oral health important?Oral health is important to:

• Eat food

• If teeth are causing pain, eating will become difficult. This can affect a person’s nutritional status and general health.

• Communicate

• It can be difficult to form words if areas of the mouth are painful or teeth are missing. To see what this is like, try saying ‘t’ and ‘s’ without letting your tongue touch your teeth.

• Socialise

• People can feel embarrassed about having decayed teeth and this may put them off opening their mouths to speak or smile. Poor oral health also leads to bad breath. This can put people off speaking.

Trainer’s noteAsk the group to think of other reasons why oral health is important to them.

Preventing social isolation is recognised as a factor in maintaining good physical and mental health.

A healthy mouth

What is a healthy mouth?• The teeth are free from plaque.

• The tooth surface is covered in enamel and free of decay.

• The gums are pink and firmly attached to the teeth.

• The soft tissues are pink and moist.

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Figure 2 shows a picture of a healthy mouth. Although this mouth has had extensive dental treatment, it is currently free from decay and has healthy gums.

Figure 2: A healthy adult mouth

What is a healthy tongue?• Pink and symmetrical, with a slightly rough surface.

Figure 3 shows an example of a healthy tongue.

Figure 3: A healthy tongue

• Tongues may have a different appearance due to conditions such as geographic tongue and black hairy tongue. These are harmless conditions but tongues do need to be kept clean. Seek advice if you are concerned.

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Figure 4 shows an example of black hairy tongue. Figure 5 shows an example of geographic tongue.

Figure 5: Geographic tongueFigure 4: Black hairy tongue

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Three steps to a healthy mouth1. Limit the amount of sugar eaten every day. If consuming food and drinks

containing sugar, keep these to mealtimes if possible.

2. Brush teeth and gums well twice a day for at least two minutes, using a 1350–1500 parts per million (ppm) fluoride toothpaste. Do not rinse the mouth out, but spit if possible.

3. Visit the dentist regularly.

Trainer’s noteEvidence suggests that rinsing the mouth with water directly after brushing makes the fluoride in toothpaste less effective at strengthening teeth and at reducing the acid produced when sugar is consumed.

What can poor oral health cause?• Pain

• Loss of teeth

• Difficulty eating

• Low mood

• Difficulty communicating

• The need for dental treatment

• In extreme cases, the need for general anaesthetic for dental treatment

Trainer’s noteCan the group share any stories which highlight the benefits of preventing dental disease?

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Oral health and adults with additional care needsThere is evidence to suggest that adults with additional care needs have poorer oral health than the general population. People with additional care needs can face many barriers to good oral health. These vary depending on the care need.

Carers can help to overcome some of these issues by developing a communication strategy with the dental team. For example, if arrangements are in place for sharing personal information, it may be helpful to involve family members or support staff.

Adults with additional care needs can also face:

• problems with transport and travelling to dental clinics

• difficulty with physical access to surgery premises

• medical or behavioural issues which may affect their ability to cope

• anxiety and fear

• problems with perceived cost of treatment

• medical problems which make dental treatment more difficult

• limited access to information

• a history of not prioritising oral health, which can be difficult to change

• a lack of perception of oral health problems, and therefore late presentation of untreated disease

• difficulties telling people what they need

• difficulties reading appointment letters, understanding when and where these appointments are taking place, and remembering to go to the appointments.

Oral diseases and conditions

What are oral diseases and conditions?Oral diseases and conditions include all those that affect the gums, tongue, soft tissues of the mouth and throat, chewing muscles and jaws. The most common oral diseases are tooth decay and gum disease. Mouth cancer can also occur, although this is less common.

Plaque

What is plaque?

• Plaque is a naturally occurring film of bacteria that forms in the mouth. It can form on all surfaces of the teeth in the mouth, including teeth themselves as well as dentures, crowns (caps) and bridges.

• It can lead to tooth decay and gum disease.

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• Everyone has it.

• If plaque is not removed from the mouth effectively, over time it can harden and become tartar (calculus).

How is it removed?

• Plaque can be removed by brushing teeth and gums thoroughly twice a day.

• Tartar can only be removed by professional cleaning.

Tooth decay

What is tooth decay?

• Tooth decay is the breakdown of the hard part (enamel and dentine) of the tooth by acids produced by bacteria in plaque.

• In the late stages of decay the tooth ‘collapses’ and a hole or cavity forms.

• Tooth decay can cause pain and lead to severe infection.

Figure 6 shows teeth with decay.

Figure 6: Tooth decay

What causes tooth decay?

• When someone eats sugar, bacteria in the plaque use it to produce acid.

• This is often called an acid attack and can cause decay to the tooth. This process is explained below:

(plaque + sugar) x time = acid attack

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• An acid attack can last from 20 minutes to two hours.

• If more food or drinks containing sugar are consumed within this period the acid attack will last longer.

• The chance of developing tooth decay can be decreased by only consuming food and drinks containing sugar at mealtimes.

How can you tell if a person has tooth decay?

You may see a discoloured or black/brown patch on a tooth, or the person might tell you they are in pain. However, people with additional care needs can have difficulty communicating. They may not be able to express that they are in pain in the way you might expect. It should be stressed that pain can be a late presenting feature of dental decay.

It is important to know the signs a particular individual uses to express themself so that you will notice when they are trying to tell you something. These might include general changes to behaviour, going off their food, losing weight, grinding their teeth, drooling, putting things in their mouth, biting and so on. The individual might also display self-harming behaviours such as scratching or picking at their skin, or biting, punching, or hitting themselves around the mouth, head or face area.

How is the risk of tooth decay reduced?

• By eating less sugar

• By only consuming food and drink containing sugar at mealtimes

• By brushing with a 1350–1500 ppm fluoride toothpaste twice a day

Please note

Any change in behaviour could indicate pain in the mouth. Please ask a dentist if you have any concerns.A tool which may help with distress assessment, the Disability Distress Assessment Tool (DisDAT), can be found in Appendix 1.

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Gum disease

What is gum disease?

There are two main stages of gum disease.

• Gingivitis: This is the first early stage of gum disease. It can be reversed by effective removal of plaque.

• Periodontitis: More advanced gum disease is called periodontitis or periodontal disease. This is when the infection damages the tooth-supporting tissue and bone. If left untreated, periodontitis can lead to receding gums, loose teeth and eventual tooth loss. It cannot be reversed, but with effective oral care and professional treatment the condition can be slowed or stopped from progressing further. Periodontitis can cause many problems including:

• difficulty eating and speaking

• decreased quality of life, as the pain of loose teeth can make people feel low

• problems with loose teeth, as they can be inhaled or swallowed. Inhalation can lead to a blockage in the airway, or teeth could be breathed into the lung.

What causes gum disease?

• Gum disease is an infection of the soft tissues and bone which surround the tooth.

• Gum disease is caused by the bacteria within plaque and poor oral hygiene.

• Gum disease is more likely to progress in people who smoke. This is because smoking reduces blood flow within the gums, causes a local immune response, and makes healing from gum disease more difficult. Smokers may not have the usual signs of gum disease such as bleeding gums.

• Smokers do not respond to gum disease treatment as well as non-smokers do, and are more likely to lose teeth.

• Some medical conditions are linked to gum problems, such as diabetes, Down’s syndrome and some heart conditions.

What are the symptoms of gum disease?

• Gum disease causes bad breath (halitosis).

• The gums bleed when brushing.

• Where plaque has not been removed, the gums around the teeth become red, inflamed and swollen.

Unit 1

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Figure 7 shows a mouth with gum disease. The gums are red, inflamed and swollen.

Unit 1

Figure 7: Gum disease

How is gum disease prevented?

• Through effective and regular removal of dental plaque by toothbrushing using a fluoride toothpaste.

• In addition, where there is enough space between the teeth, use mini-interdental bottle-type brushes to clean between the teeth. To ensure correct use, seek advice and instruction from a dental professional.

Non-carious tooth surface loss[Loss of tooth surface not caused by decay]

Teeth can be damaged by conditions other than tooth decay. Instead of a cavity, sometimes the surface of the tooth can be lost in the following ways.

• Erosion

• This occurs when the tooth surface is dissolved by acids. These are different acids from those which cause decay. Erosion can be caused by acids in the diet, such as fruit juices, carbonated drinks and citrus fruits, or by acid reflux from the stomach.

Trainer’s noteWhy do you think gums would bleed?

Bleeding gums do not always mean that the gums have been brushed too hard or pricked with a toothbrush bristle. Gums can bleed because they have become inflamed due to plaque.

Note: to reduce plaque and stop gums from bleeding, effective toothbrushing should continue twice daily.

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• Abrasion

• Abnormal wearing away of tooth tissue by a mechanical process, such as over-vigorous toothbrushing.

• Attrition

• Wearing away of the tooth surface as a result of tooth-to-tooth contact, such as tooth grinding.

In reality, these three do not occur in isolation, but are often found in combination.

Diet and oral healthAs previously stated, one of the key factors leading to tooth decay is the consumption of sugar. Everyone eats and drinks sugars on a daily basis but there are two issues that determine whether or not these sugars will lead to tooth decay:

• type of sugar

• amount and frequency of consumption.

What are the different types of sugars?Sugars occur naturally in certain foods and drinks, such as fruit and milk. These types of sugars are not linked to tooth decay.

The main type of sugar that leads to tooth decay is called ‘free sugar’. This is generally the kind of sugar which is added to food when it is being made or cooked, but also includes sugar found in honey, syrups and fruit juices. Almost three-quarters of all the sugars consumed in the UK are added sugars. Some examples of foods or drinks with added sugars are:

• fizzy drinks and juice drinks

• sweets and biscuits

• jam

• cakes, pastries and puddings

• ice cream

• energy drinks

• processed foods such as ready meals, breakfast cereals, baked beans or cereal bars.

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Amount and frequency of sugarEvery time sugar is eaten, it causes an acid attack. There is generally some level of sugar present in every meal (i.e. breakfast, lunch and dinner). Therefore, if food and drinks containing sugar are only consumed at meal times, this will limit the number of acid attacks on the teeth. However, if a person continues to snack on food and drinks containing sugar between meals they will have more acid attacks and therefore increase their chances of developing tooth decay.

Unit 1

Please note

Additional information

If fruit is juiced or blended, the sugars are released. Once released, these sugars can damage teeth, much like added sugars.

Trainer’s noteTry using Activity 1 (Appendix 2) to get participants to think about foods and drinks that contain sugar.

For more information on food labelling see Oral Health and Nutrition Guidance for Professionals, published by NHS Scotland. www.healthscotland.scot/publications/oral-health-and-nutrition-guidance

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If food and drinks containing sugar are only consumed at mealtimes then the saliva produced by eating will help to protect the mouth. Saliva is the mouth’s natural defence against acid attack; it helps to neutralise acids and wash away sugars. Moreover, if sugar is only consumed at mealtimes, its effects are reduced as it is cleared away by the other food being eaten.

Research shows that bedtime is the worst time to have food and drinks containing sugar. People produce less saliva when they are sleeping and it is unlikely that brushing will remove every last trace of food from the mouth. Therefore, if a person eats something sugary last thing at night, even if they brush their teeth, they are likely to still have traces of sugar in their mouth while they sleep and no saliva to neutralise an acid attack.

Unit 1

Additional information

Trainer’s noteTry using Activity 2 (Appendix 2) to help participants to think of ways they could encourage those in their care to eat less sugar, less often.

It is the frequency rather than the amount of sugar consumed which increases the number of acid attacks. Even a small amount of sugar will cause an acid attack. No matter how much sugar is consumed, the mouth will take the same length of time to recover from an acid attack.

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Trainer’s noteIt may be helpful to introduce the people you are training to some of the initiatives available to help with cooking and other useful skills.

It might also be a good idea to do some research into some local community initiatives in advance, so that you can direct people towards ways of learning about good food.

For example:

Development of the new Eatwell Guide

The Eatwell Guide has replaced the Eatwell Plate as the main tool to show you a healthy balanced diet. It no longer represents a ‘plate’ but still shows the proportions of food and drinks that make up a healthy diet. The proportions of the food groups have been updated to take into account new dietary recommendations that we eat more fibre and less sugar. Available at: www.foodstandards.gov.scot/consumers/healthy-eating/eatwell

Community Food and Health (Scotland) or CFHS

CFHS aims to ensure that everyone in Scotland has the opportunity, ability and confidence to access a healthy and acceptable diet for themselves. CFHS supports low-income communities by working with them to address health inequalities and barriers to healthy and affordable food. Some examples of these barriers are culture, food availability, food costs and a lack of cooking skills. Available at: www.communityfoodandhealth.org.uk

Eat Better, Feel Better

This has lots of recipe ideas, helpful hints and suggestions on how to save money on healthy food. Available at: www.eatbetterfeelbetter.co.uk

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High-energy diets, prescribed nutritional supplements and snacksSome people may be on a high-calorie diet or prescribed supplements and snacks. This may increase both the amount of sugar in their diet and the frequency of its consumption. As these people have a higher risk of tooth decay, they may need more intensive mouth care. This could include using a high-strength fluoride toothpaste or regular use of fluoride mouthwash on instruction from the dentist.

An alternative to using high-strength fluoride toothpaste may be to continue using normal toothpaste (1350–1500 ppm fluoride), but to increase frequency of brushing.

Trainer’s noteSome individuals might not understand that they have to spit out mouthwash, not swallow it. Be careful when encouraging the use of this product.

Please note

This advice depends on the individual and these changes may not be possible. Talk to a dental professional to look at ways of maintaining the oral health of the person you are caring for. If you have any concerns or if the person is under the care of a dietitian please liaise with them.

Other factors which may have an impact on oral health

MedicationsMany medications can have an effect on oral health. The effects can range from having a dry mouth to making tooth decay more likely.

• Medications which are syrupy can cause plaque to remain on the teeth for longer. This makes decay more likely, so it is important to brush teeth after taking the medication. If this is not possible, rinsing out the mouth will help.

• Where possible, medications should be sugar free. If these are not suitable, the individual should brush their teeth more often.

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• The use of inhalers can leave a film over the teeth, which causes plaque to build up and may increase the chance of tooth decay. It also increases the risk of oral thrush. Therefore, it is important to rinse and then swallow after using inhalers to remove the film, and to make sure all the medication in the inhalers is absorbed.

• Iron supplements can cause harmless black staining on the teeth. This can be prevented by regular brushing.

• If medication is stored in the mouth and not swallowed, this can cause ulceration of the tissues near where the medication is being stored. This can be very painful so it is important to ensure that medication is swallowed, or chewed if appropriate. If the problem persists, taking the medication in liquid form is a good alternative if available.

Dry mouth

What causes dry mouth?

A dry mouth is caused by a lack of saliva. This may be because of a medical condition, such as Sjogren’s syndrome, or because of certain drugs, such as antidepressants, antihypertensives, anti-reflux agents, diuretics and many others. It may also be caused when a person is on several medications at one time (polypharmacy).

Figure 8 shows the tongue of someone experiencing dry mouth.

Figure 8: Dry tongue

What are the effects of a dry mouth?

A dry mouth can make a person feel uncomfortable and can make it difficult to swallow and eat, which can lead to malnutrition. It may also be difficult to speak and to wear dentures.

Dry mouth also has a harmful effect on oral health, as saliva acts as a natural barrier to teeth and neutralises the acid created while eating. People with dry

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mouth are more at risk of tooth decay, periodontal disease and infection of the oral soft tissue, which covers the inside of the mouth.

How to relieve the symptoms of a dry mouth

• Advise the person you are caring for to:

• take frequent sips of water

• clear the mouth after eating.

• Refer the person to a dental clinic. The dentist may provide or prescribe:

• a saliva substitute – for example, a water-based saliva replacement gel

• a high-strength fluoride toothpaste

• a fluoride mouthwash.

SwallowingIf an individual has difficulty swallowing, carers need to ensure that the person’s mouth is cleared of food and fluids, particularly if fluid thickeners have been used.

Dysphagia

Dysphagia is the medical term for difficulty swallowing. The three main health complications of dysphagia are under-nutrition, dehydration and pneumonia.

A health professional such as a speech and language therapist should carry out an assessment for individuals experiencing dysphagia, and a specific oral health plan should be established.

Signs of dysphagia may include:

• problems eating or drinking, or a feeling of obstruction

• a gurgly, wet or hoarse voice, and frequent clearing of the throat

• coughing or choking with or after food and/or drink

• taking a long time to eat meals, or changed eating habits

• food remaining in the mouth after eating

• recurrent chest infections or pneumonia, or unexplained temperature spikes

• drooling/dribbling

• refusing certain types of food

• pain or difficulties with chewing or swallowing

• unexplained weight loss.

Additional points when caring for someone with dysphagia

If the person has 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.

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• Use a small-headed toothbrush and a smear of non-foaming fluoride toothpaste (without sodium lauryl sulphate) to clean natural teeth.

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

If the person has dentures:

• Be careful with denture adhesives. Use the minimum amount.

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

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

• Do not use mouthwash if the person has dysphagia. This is due to the risk of choking or aspiration (breathing in the mouthwash).

• 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.

BruxismBruxism is the grinding of teeth which serves no purpose. It can lead to toothwear (attrition) and exposure of dentine (the softer inner layer of the tooth). In some severe cases, this can cause pain and infection. Bruxism is common in people with additional care needs but there is very little research on treatment options. Bite guards, which are plastic devices worn at night to prevent grinding, can help to prevent damage but individual assessment is required.

SensitivityAgeing, overbrushing or gum disease can make gums recede, which may cause the necks of the teeth (where the tooth meets the gum) to become sensitive. This can be helped by using toothpaste for sensitive teeth instead of regular toothpaste, or by brushing with regular toothpaste and then rubbing toothpaste for sensitive teeth directly onto the affected areas. Seek advice from a dentist if sensitivity continues, as fluoride application may help.

Additional information

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Please note

Mouth cancerThe main risk factors for mouth cancer are smoking and drinking alcohol. Other things which can increase someone’s risk of oral cancer include:

• chewing tobacco or paan (chewable tobacco)

• the human papillomavirus

• pre-cancerous conditions

• eating a diet which is low in fruits and vegetables

• exposure to chemicals

• exposure to sunlight (for lip cancer).

Things to look out for include:

• red or white patches

• lumps in the mouth

• ulcers that do not heal after two weeks

• persistent soreness in the mouth.

Other oral cancer symptoms may include jaw swelling, unusual pain or bleeding in the mouth.

If you notice any of these symptoms, make an appointment with a dentist.

Remember – if in doubt, get it checked out. (See Appendix 4 for contact details for NHS Inform).

See page 61 for making a referral to a dentist.

If you notice any of these symptoms in yourself, you should make an appointment with your dentist.

Unit 1

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Unit 2: Practical daily oral care

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Unit 2: Practical daily oral careKey points• Oral care is the responsibility of every carer.

• Effective daily oral care can prevent oral disease.

• Looking after soft tissues is as important as looking after teeth.

This unit will cover• Good oral hygiene, including toothbrushing skills and effective dental products.

• Good oral care practice, including effective denture hygiene and soft tissue care.

• Strategies that can overcome barriers to delivering oral care.

Cleaning teeth and soft tissuesThese are general points for guidance. They will need to be adapted depending on the individual and the care setting. Try to establish a regular oral care routine.

What are some good hygiene practices for oral care?• Wash your hands before and after toothbrushing.

• Wear disposable gloves when carrying out oral care for someone else.

• Cover cuts, abrasions and breaks in the skin with a waterproof dressing.

• After brushing, rinse toothbrushes well and store them upright or in individual ventilated holders.

• Ideally, replace toothbrushes every three months, or sooner if required.

• Do not soak toothbrushes in cleaner or disinfectant.

• Clean tubes of toothpaste with a damp tissue.

What is the most effective kind of toothbrush?• Use a small toothbrush to give easier access to every surface of the teeth,

especially the hard-to-reach back teeth.

• Bristles should be a soft-to-medium texture.

• The toothbrush should be replaced when its bristles become splayed, because they will be less effective at removing plaque.

• Some individuals may choose to use an electric toothbrush.

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Figure 9 shows examples of effective toothbrushes. Note how small the head of the toothbrush is in relation to the handle.

Figure 9: Effective toothbrushes

Trainer’s noteIf possible, a practical demonstration of toothbrushing is the best option. Alternatively, see Activity 3 (Appendix 2).

Fluoride toothpasteIt is important to use toothpaste that contains fluoride. Fluoride helps to strengthen teeth and to act against the acid produced when sugar is consumed. You can find out how much fluoride a toothpaste contains by looking at its ingredients. Toothpaste should contain between 1350 and 1500 ppm fluoride (this will be listed as ppm fluoride in the ingredients).

Most toothpastes contain sodium lauryl sulphate (SLS) which is a chemical used to create the foaming action. In some cases, an SLS-free alternative is worth considering.

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Figure 11 shows a pea-sized amount of toothpaste, the appropriate amount to use.

Unit 2

Figure 11: The appropriate amount of toothpaste

Trainer’s noteFlavourless toothpastes and toothpastes with flavours other than mint are available. Some individuals may prefer these. Non-foaming toothpastes are also available.

Figure 10 shows examples of fluoride toothpastes.

Figure 10: Fluoride toothpastes

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What should you do before toothbrushing?• Encourage the person you are assisting to do as much as they are capable

of themselves. Be prepared to prompt, encourage or assist as necessary.

• Choose a suitable time, when you and the person you are caring for are relaxed.

• If you are required to carry out oral care for someone else, always explain what you are going to do first; brushing someone else’s teeth involves entering personal space.

• Tell them why you are doing it.

• If appropriate, develop communication signs so that they can tell you if they would like you to stop.

• Consider using pictures to go along with the process.

• Make sure the person is comfortable. For example, they might want to be seated in front of a washbasin, in their wheelchair, on the bed or on the floor. You should make sure their head is well supported and their dignity and privacy are respected.

• Decide on an ‘order of brushing’ that you are going to use. For example:

Upper teeth and gums

• Outside surface

• Inside surface

• Chewing surface

Lower teeth and gums

• Outside surface

• Inside surface

• Chewing surface

It does not matter what order you do this in, but make a list before toothbrushing so that you do not miss any areas. If cooperation is limited, brush different areas of the mouth at different points in the day, and start with a different area each day.

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Soft tissues

What are soft tissues?

• The tongue

• The lips

• The inside of the cheeks

Care of soft tissues

Even if a person has no natural teeth it is important to clean their soft tissues. This should be carried out daily with either a moist, soft toothbrush or dampened gauze. If the person has dentures, these should also be cleaned as this will help to remove plaque and maintain good oral health.

Suggested equipment

• Disposable gloves

• Gauze

Procedure for cleaning using a toothbrush

• Use a soft-textured toothbrush.

• Wet the toothbrush to further increase softness.

• You may want to use a little toothpaste to freshen the person’s mouth.

Procedure for cleaning using gauze

• Gauze and a gloved finger can be used to clean and moisten the mouth. This is sometimes the preferred option for carers.

• The gauze must be thoroughly soaked in water.

• Change the gauze if needed. You may need several pieces.

Do not cut the gauze, as loose threads could be accidentally inhaled.

If there is a risk of a person biting when fingers are in their mouth, carers should assess the risk before starting to help with oral care.

Please note

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Steps for cleaning natural teeth, soft tissues and dentures

Brushing teeth and gumsBelow is an outline of steps for brushing teeth and gums. These steps do not have to be followed in the exact order outlined. However, decide on an order of toothbrushing to ensure no areas are missed.

Additional informationSponge sticks

• These are not recommended. Alternative products are available.

• Sponge sticks do not remove plaque from tooth surfaces and should only be used to moisten or clean the soft tissue inside the mouth.

• One problem with sponge sticks is that the foam sponge can come off the stick and be inhaled. This seems to happen when the stick has been allowed to soak.

See Medical Device Alert MDA/2012/020 (13 April 2012).

• Sponge sticks must not be used if the person clenches their teeth uncontrollably, as the stick could break in the mouth.

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

prompt – encourage – support Promote self-care as much as possible.

Step 1Discuss the procedure with the individual.

Step 2Make sure the individual is in a comfortable position to have their teeth brushed. Try different positions to suit their needs, making sure their head is supported.

Please note

These techniques should not involve any physical force or be done against someone’s will. You should also consider whether the individual has any swallowing issues or a physical disability that might make particular techniques dangerous. For example, there may be a risk of choking, or of falling if they are unstable.

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Step 3Put a pea-sized amount of toothpaste on the toothbrush (remember this should contain 1350–1500 ppm fluoride).

Step 4Gently draw back the lips with your thumb and forefinger on one side of the mouth to gain access to the upper teeth.

Please noteTechnique for brushing:• Brush each tooth for a count of six.• Make sure the toothbrush is in contact with the gum margins

(where the tooth meets the gum).• Use circular motions or short horizontal movements to remove

plaque from teeth and gums.

Step 5Brush the outside surface of the upper teeth and gums.

Step 6Brush the inside surface of the upper teeth and gums.

Step 7Brush the biting surface of the upper teeth and gums.

Please note

If teeth are loose, brush them carefully. You should still try to clean them every day.

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Step 8Brush the outside surface of the lower teeth and gums.

Step 9Brush the inside surface of the lower teeth and gums.

Please note

Even if the gums bleed, continue to brush them. Bleeding is usually the result of plaque build-up and only continued gentle brushing can remove this.

Step 10Brush the biting surface of the lower teeth and gums.

Step 11If possible, gently brush the tongue.

Step 12Allow the person to spit out the froth from the toothpaste but encourage them not to rinse their mouth out with water.

Only rinse the brush once toothbrushing is completed.

Trainer’s noteEvidence suggests that rinsing the mouth with water directly after brushing makes fluoride toothpaste less effective at strengthening teeth and at reducing the acid produced when sugar is consumed.

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Denture care

Please note

If the individual does not have any natural teeth or wears dentures, use the above steps to clean the soft tissues but use a moist, soft toothbrush or dampened gauze instead of a normal toothbrush.

Mouthwashes do not replace toothbrushing. There is no substitute for the mechanical removal of plaque.

Trainer’s noteUse Activity 3 (Appendix 2) to develop toothbrushing techniques.

Why should you clean dentures?

• Poor denture hygiene can cause oral thrush and an overgrowth of tissue below the denture.

• Cleaning dentures regularly reduces the risk of oral thrush and gum disease.

Please note

It is important to remove dentures at night.

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How should dentures be cleaned?

• Rinse dentures after every meal.

• Clean dentures morning and night using a toothbrush and denture cream, or plain soap and water. Do this over a filled basin or a soft surface to reduce the risk of breaking the dentures if you drop them.

• Soak dentures in disinfecting solution for at least 20 minutes once a day.

• Soak dentures overnight in plain water.

What are the benefits of using sodium hypochlorite to clean dentures?

• Popular products are not completely effective at cleaning dentures.

• Fizzy cleansers do not completely kill bacteria or fungus growing on dentures.

• Research shows that soaking dentures in sodium hypochlorite after brushing is effective at killing bacteria or fungus growing on dentures, and therefore prevents oral thrush.

Metal-based dentures should be soaked in chlorhexidine mouthwash, providing the person has no known allergy to it.Remember to clean the soft tissues of the mouth and the tongue.Individuals who have no natural teeth and only dentures should still visit their dentist regularly for check-ups.

Please note

It is important to check the medical history for any previous allergies.

See Medical Device Alert MDA/2012/075 (25 October 2012).

Practical tips for those who are tube fedThis includes feeding by gastrostomy, jejunostomy and nasogastric tube. People may be tube fed because of an inadequate diet, nutritional needs, and/or impaired swallowing.

Tube fed people may suffer from:

• dental erosion related to gastro-oesophageal reflux and reduced saliva production

• dry mouth because they have reduced salivary flow

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• dental decay, rapid tooth destruction, dryness and cracking of the lips, crusting of the tongue and build-up of calculus on the teeth

• difficulty protecting their airways due to lack of coordination of swallowing with breathing.

Oral careOral care for people who do not eat or drink is often forgotten but is essential.

If the person has natural teeth, follow the steps outlined in the toothbrushing section starting on page 38, but with the following advice added:

• Check the mouth before brushing for any debris. Clear this out of the mouth using a toothbrush or a moist gauze on a gloved finger.

• Use a non-foaming toothpaste (no sodium lauryl sulphate).

• It may be advisable to keep the person upright for a while after toothbrushing, to reduce the risk of choking or aspiration (breathing in foreign objects).

If the person has dentures, follow the steps outlined in the denture cleaning section starting on page 41, but with the following advice added:

• Extra care must be taken if denture fixative (adhesive) is being used. Check the instructions and use the minimum amount.

Please note

People who are PEG fed and tube fed still have plaque forming in their mouth. If this is not removed it will become tartar. This can be very difficult for a hygienist to remove because of the risk of aspiration (breathing in foreign objects). It is therefore vital that good oral hygiene is maintained for those who are PEG or tube fed. It might be appropriate to have a multi-disciplinary care plan in place to ensure the safety and oral health of people who are PEG or tube fed.

Possible complications Staphylococcal mucositis can occur in people who are fed through nasogastric or PEG tubes, people on intravenous fluids, and unconscious individuals who mouth-breathe.

Appearance

• Dry, crusted and possibly bleeding lips

• A dry mucus ‘crust’ on the palate and tongue, and possibly elsewhere in the mouth

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Figure 12 shows the mouth of someone with staphylococcal mucositis.

Figure 12: Staphylococcal mucositis

Prevention

• Clean the mouth three or four times daily, depending on the person’s condition.

• If this is not done, the individual risks getting aspiration pneumonia if any of the crust falls off and reaches the airway.

Treatment

It is vital that the mouth is cleaned every three hours. The crust-like mucus must be softened thoroughly before removal with either water or chlorhexidine, which can be diluted. Several attempts at cleaning may be necessary to completely remove crust which has already dried on the surface of the soft tissue.

The method for cleaning the mouth is the same for prevention and treatment.

• The soft tissue should be swabbed with chlorhexidine mouthwash on a gauze square or sponge stick (preferably a gauze square).

• Suction should be used as required.

• Natural teeth can be cleaned with chlorhexidine gel on a toothbrush.

• If the patient has difficulty opening their mouth or keeping it open, a dental mouth prop may help you gain access.

• Normal toothpaste must not be used to clean the teeth as the patient might inhale the froth from the toothpaste. Use non-foaming toothpaste instead.

A sponge stick should not be used if the individual clenches their teeth uncontrollably, as the stick could break in the person’s mouth.

See Medical Device Alert MDA/2012/020 (13 April 2012).

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Palliative careSymptoms related to the mouth are common when a person requires palliative care, so it is important that oral care at this time is not overlooked. Examination, assessment and re-examination of the mouth are some of the most important tasks. Mouth care should be carried out regularly to ensure the person is kept as comfortable as possible.

If the person has a healthy mouth• Assess them daily for changes.

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

• Use damp gauze wrapped around a gloved finger if the person is unable to tolerate a toothbrush. The gauze should be non-fraying. Wet it thoroughly in clean running water before you use it.

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

If the person has a painful mouth• If possible, identify the cause. Refer the person to a dentist urgently.

• If the pain is caused by a dry mouth, water-based saliva replacement gels can help.

• If dietary advice is required, ask a dietitian or nurse.

• If the person has painful mouth ulcers, identify the cause if possible. Refer the person to a dentist urgently.

• If there is general redness of the soft tissues, this could be a bacterial infection. These bacteria can also cause respiratory tract infections such as pneumonia.

• If a person is receiving cancer treatment and they develop oral thrush, specialist advice is crucial. Oral thrush in cancer patients can be very serious as it can prevent the person from swallowing.

Additional products and aids

Toothbrush adaptationsIf a person is able to carry out their own oral care they should be encouraged to do so. They can use either a manual or an electric toothbrush. If they have limited dexterity, adapted toothbrushes can help – for example, you can use foam tubing or a foam ball to provide grip.

If you have no success finding the appropriate adaptors, ask for a referral to the local occupational therapy department for advice.

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Figure 13 shows different adapted toothbrushes.

Figure 13: Adapted toothbrushes.

Mouthwashes and gelsMouthwashes and gels are often recommended to supplement toothbrushing or to treat gum inflammation.

It is important when using mouthwashes and gels to discuss their use with a dental professional, as they do have some disadvantages.

• Severe allergic reactions have been linked to some mouthwashes and gels, so it is essential to discuss any existing allergies with a dental professional.

It is important to check the medical history for any previous allergies.

See Medical Device Alert MDA/2012/075 (25 October 2012).

• Many mouthwashes contain alcohol and so using them too much should be avoided. They should also not be used by anyone experiencing the symptoms of a dry mouth, as the alcohol will make the dry mouth worse.

• Gels are often applied directly to the mouth, so it is essential to follow the advice of a dental professional to make sure they are applied correctly.

ChlorhexidineChlorhexidine is an effective plaque suppressant if it is used after teeth have been thoroughly cleaned.

Unit 2

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• Chlorhexidine:

• can be prescribed by a dentist or doctor and also purchased from pharmacies without prescription

• comes in many forms, such as gel, spray, toothpaste and as a daily rinse

• can impair taste and cause staining of the teeth if used for a long time

• should only be used as directed, a maximum of twice a day

• should be used for short courses of about one month – it can be used as part of treatment for acute gingivitis

• is still effective if it is diluted 50/50 with water.

Figure 14 shows some chlorhexidine mouthwash and gel.

Figure 14: Chlorhexidine mouthwash and gel

Overcoming specific barriers in oral careListed below are problems you might face while carrying out oral hygiene with someone you are caring for, and possible solutions to these problems. If these are not successful, ask a dentist or a hygienist for advice.

• Biting on the toothbrush

• Allow the person to continue biting on one toothbrush while you clean their teeth with another toothbrush.

• Strong tongue thrust

• If the person’s tongue moves around a lot, or their lips are pressed tightly together, this may push the toothbrush out of their mouth or away from their front teeth. If this happens, use a flannel or gauze square wrapped around your forefinger to gently retract or hold back the tongue or lip. This will need patience and perseverance.

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• Gagging or retching on brushing

• To reduce gagging and retching, it may be helpful to start brushing from the back teeth and move forward. Extra moisture in the mouth can encourage or worsen a gag reflex, so remember not to wet the toothbrush before brushing.

• Try carrying out short episodes of toothbrushing at a time. Be aware that this may increase the length of time required for toothbrushing. Consider using non-foaming toothpaste (no sodium lauryl sulphate). You can also try different types of toothpaste to find one that the person you are caring for prefers using.

• You may find that the person gags less at different times of the day. If this is the case, carry out toothbrushing whenever they gag least. For example, if someone gags more in the morning but less in the afternoon, brush their teeth in the afternoon and then again at bedtime.

Ways to help individuals who find oral care difficultIndividuals with cognitive impairment may not understand what is being asked of them. They may become afraid or they may be in pain and unable to communicate. Oral care can then become difficult.

You may have to brush different areas of the mouth on separate occasions. Keep a note of the area brushed each time. Sometimes the easiest or the only way to brush someone’s teeth is while they are in bed. If this is the case, then it is important to be aware of the risk of choking if they are not upright.

Time and place• Develop a routine with oral care. Carrying this out at the same time every day

may help. People with cognitive impairment may have routines they like to follow, so consider asking family members or previous carers for advice or help.

• Sometimes a person may respond better to one well-known carer, or sometimes it may be useful to have another carer helping.

• Carry out oral care in a quiet, distraction-free environment with enough light to be able to see into the mouth. The location should be a place the person is comfortable. It should be as private as possible to preserve dignity.

Communication strategies• Be caring, calm and friendly. Smile.

• Talk clearly, at the individual’s pace.

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

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

• Use reassuring and appropriate body contact and gentle touch.

• Remain positive and try not to show any frustration.

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Behaviour strategies• Be aware of the individual’s needs.

• Think about position – don’t approach the person from behind. Instead, come down to eye level. Be aware of the need for personal space.

• Ensure the individual is relaxed. If necessary, be willing to slow down or try again later.

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

Trainer’s noteIf someone shows reluctance, research has shown the strategies below may help.

• Bridging

• This helps to engage a person with the task through their senses and helps them to understand the task. Describe and show them the toothbrush, then mimic brushing your own teeth. Give another toothbrush to the individual. They may mirror your behaviour and brush their own teeth.

• Chaining

• This involves gently bringing the person’s hand to their mouth while describing the activity. Let them continue brushing if they are able.

• Hand over hand

• If chaining is not successful, then place your hand over the individual’s hand and gently brush their teeth together.

• Distraction

• If none of these strategies work, try distracting the individual by placing a familiar item in their hand while you brush their teeth. Other distractions such as music may be helpful.

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Trainer’s noteNHS Health Scotland has produced a Care Related Stress and Distress DVD with accompanying guidance for the Caring for Smiles programme for dependent older people. This may also be relevant for adults with additional care needs. To get a copy, contact your local NHS oral health team.

• Rescuing

• This is a common tactic used with other hygiene tasks. If attempts are not going well, the carer can leave and a ‘rescuer’ comes in to take over. Bringing in someone else with a fresh approach may encourage the individual to cooperate.

Unit 3: Oral health documentation

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Unit 3: Oral health documentationKey points• Oral health documentation is important.

This unit will cover• What each document is used for.

• Appropriate use of oral health documentation, including oral health risk assessments, care plans and daily care records.

Trainer’s noteSome carers may work in a residential setting but it is important to remember that others may be carers for family members, partners or friends. The use of some oral health documentation will not be relevant to them. However, this could be an opportunity to outline best practice and local processes where oral health documentation is completed. If there is more than one carer it may be helpful to keep a diary of the individual’s preferences, successes and disappointments.

You could start this section by asking participants what they think about documentation. Encourage them to share positive and negative experiences.

Why oral health documentation should be completedVarious published documents recommend that:

• a simple oral health risk assessment should be carried out on all people within 48 hours of being admitted to residential care

• after individual assessment, a written care plan should be produced.

The risk assessment helps staff to identify any problems as early as possible and to create a care plan that is tailored to the individual. This should be reviewed regularly to make sure that any changes are picked up on.

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Step 1

Oral health risk assessmentsThe oral health risk assessment contains a series of questions that you should answer about the person you are caring for, either by asking them or by looking into their mouth.

An oral health risk assessment will allow you to identify any risks to an individual’s oral health and give you advice about what you should do in response to the risks. It also allows the development and implementation of an individual oral care plan, which indicates the daily oral care assistance required.

Additional information

If you need help with conducting oral health risk assessments, contact your local NHS oral health team.

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Step 2

Oral care plansAfter an oral health risk assessment, an oral care plan should be completed.

The oral care plan has tick boxes that allow you to note any actions that you are going to take to improve and maintain the oral health of the person you are caring for. Tick the appropriate boxes to indicate which areas of the mouth require care and whether the individual needs support or encouragement from staff to carry out that care.

There is also a notes section where you can record any changes. You can add a note if, for example, the individual has visited the dentist or is on medication with oral side effects, or a dental referral has been made.

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Step 3

Daily oral care recordsThe daily oral care record allows you to make a note of the type of oral care that is being carried out on a daily basis, and who is carrying this out. Providing a summary of a month’s oral care will also help you to spot if someone is struggling with their oral care.

• If a carer is carrying out, or supporting someone in, daily oral care they should tick the box indicating that they have completed care. If the care has not been carried out they can use a code to record this.

• The carer should sign their name.

• The record should be checked by a senior member of staff where applicable, and signed weekly to make sure the oral care is being carried out.

• On completion of four weeks of daily oral care, the oral health risk assessment should be reviewed in case changes are needed. A new oral care plan should be completed.

• Oral care plans and daily oral care records should be kept in a central folder that is easily accessible on a daily basis.

Keeping this record up to date also helps the dental team to see what issues have come up since their last visit and highlights particular problems for them to address.

Trainer’s noteYou could try using Activity 4 (Appendix 2) to develop participants’ skills in completing oral health documentation. There are case studies in Appendix 3 which participants can use to complete risk assessments and care plans, as well as to consider the use of daily documentation charts.

If people carry out their own oral care the daily documentation can be completed if desired.

Please note

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Daily oral care Month: _____________________________

Name___________________________________________________________

Day

Natural teeth Dentures Soft tissue

care Unable to provide oral care notes/codes InitialsPlease tick: Please tick: Please tick:

AM PM 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

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

Codes: unable to provide oral carePatient stress and distress A Staffing levels CPatient asleep B Other D

Comments:__________________________________________________________________

___________________________________________________________________________

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Three steps to ensure daily oral care is tailored to each individualThis flow chart shows the stages involved in making sure that daily oral care is suited to the individual.

Step one:Oral health risk assessment

Step two:Develop an oral care plan

Step three:Document daily oral care

Refer to dentist if required

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Dental referralsThis is general guidance only and will vary depending on your local area.

Why should someone be referred to a dentist?The oral health risk assessment highlights specific reasons why someone should be referred to a dentist. If the person is already registered with a dentist, carers should support them by making sure they continue to be registered. If they do not have a dentist, carers should help them to register as quickly as possible.

Type of referral Reason for referring

Urgent referral to a dentist (by phoning a dentist)

If the person complains about, or if there is evidence of the following: • Facial swelling • Painful natural teeth • Non-healing ulcers • Decayed or broken teeth

Non-urgent referral to a dentist (by sending in a referral form or by phoning a dentist)

If the person has not had a dental check-up in more than two years

If they have dentures that are more than five years old

If the person complains about, or if there is evidence of, the following: • Bleeding gums • Lost dentures • Denture problems • Dry mouth

How to make a referralGeneral Dental Service

• If someone is registered with their own dentist, contact their dentist to make an appointment.

• The individual should be informed of the appointment and supported, if necessary, to get there.

• If they are not registered with a dentist but would be able to attend a regular high street dentist, you may wish to call round various practices and ask to register and make an appointment.

• If it is not possible to get an appointment, contact the Public Dental Service.

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Public Dental Service (previously known as Community Dental Service, or Salaried Dental Service, etc.)

• If someone is unable to register with a General Dental Practitioner they can access treatment with the Public Dental Service.

Referrals can be made by calling the local dental helpline during office hours. The helpline number can found on the website www.nhsinform.scot by searching for ‘dental emergencies’.

For dental emergencies out of hours please contact NHS 24 on 111 (this number is free to call). Dental emergencies include swelling, restricted swallowing, swelling extending to the eye, uncontrolled bleeding or trauma (for example, knocking out a tooth).

Please note

If possible, please ensure a full medical history form is completed and taken to the appointment. If a medical history form is not available, try to gather as much information as possible from the individual or their GP.

Who gets help with dental charges?In Scotland, NHS dental examinations are free of charge for everyone.

After carrying out an examination, the dentist may suggest that treatment is needed. Unless exempt, NHS patients pay 80% of the treatment costs (including any X-rays), up to a maximum of £384. Correct 1 November 2018.

Additional information

Everyone should have dental examinations, regardless of dental condition or age. These examinations allow the dentist to check for oral diseases, including oral cancer, and enable early detection and treatment. People without natural teeth should also attend regularly but the dentist may advise that 24 months between examinations is enough. Those at greater risk of oral disease, including smokers, may need more frequent appointments. Individuals should take the specific advice given by their dentist.

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A person is automatically exempt from payment for dental treatment if they:

• are under 18

• are aged 18 and in full time education

• are pregnant

• have had a baby in the last 12 months.

A person may be exempt if they or their partner is entitled to, or named on, a valid NHS Tax Credit Exemption Certificate, or if they receive:

• Income Support

• Universal Credit

• Income-related Employment and Support Allowance

• Income-based Jobseeker’s Allowance

• Pension Credit Guarantee Credit

To qualify for free treatment because a partner receives benefits, the award letter must say that the exemption applies to the partner.

If a person is not on these benefits they will need to complete an HC1 form to find out if they are eligible for part or full exemption from dental fees. You can get an HC1 at community pharmacies, GP practices, Citizens Advice Scotland offices and Job Centre Plus offices.

Trainer’s noteNHS Health Scotland produced ‘A guide to dental services, treatment charges and exemptions for care home residents’ as a resource for the Caring for Smiles programme for dependent older people. A lot of the information is also relevant to adults with additional care needs, so this might be a useful source of reference. www.healthscotland.com/documents/25418.aspx

Please note

Please make sure you are aware of the benefits the individual receives, or that the individual is able to explain these themselves, when you accompany them to their dental appointment.

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Glossary and appendices

67

Glossary

GlossaryCalculusPlaque which is not removed eventually hardens and becomes calculus. This can cause inflammation of the gums.

DentineThe sensitive layer of the tooth, underneath the enamel.

EnamelThe enamel layer is the very hard outside layer of the tooth. It is designed to protect the dentine layer.

GingivitisThe early stage of gum disease is called gingivitis. Symptoms include swollen red gums and bleeding when you brush your teeth or eat hard foods.

PEG feedingPercutaneous endoscopic gastrostomy (PEG) is a method of feeding people use when taking food through the mouth is either not possible or not safe.

PeriodontitisMore advanced gum disease is called periodontitis or periodontal disease. This is when the infection damages the tooth-supporting tissue and bone.

Plaque Plaque is a naturally occurring film of bacteria that forms in the mouth. It can form on all surfaces of the teeth in the mouth, including teeth themselves as well as dentures, crowns (caps) and bridges.

Tooth decayTooth decay is the breakdown of the hard part of the tooth (enamel and dentine) by acids produced by bacteria in plaque.

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Appendix 1

Appendix 1: Disability Distress Assessment Tool (DisDAT)

Individual’s name:

Date of birth: Gender:

NHS No:

Your name:

Date completed:

Names of others who helped complete this form:

The Distress PassportSummary of signs and behaviours when content and when distressed

Face

Jaw and tongue

Eyes

When content When distressed

Vocal sounds

Speech

Habits and mannerisms

Comfortable distance

Body posture

Body observations

Known triggers of distress (write here any actions or situations that usually cause or worsen distress)

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Appendix 1

The Disability Distress ToolPlease take some time to think about and observe the individual under your care, especially their appearance and behaviours when they are both content and distressed. Use these pages to document these.

We have listed words in each section to help you to describe these signs and behaviours. You can circle the word or words that best describe the signs and behaviours when they are content and when they are distressed.

Your descriptions will provide you with a clearer picture of their ‘language’ of distress.

Communication level*

This individual is unable to show likes or dislikes Level 0

This individual is able to show that they like or don’t like something Level 1

This individual is able to show that they want more, or have had enough of something

Level 2

This individual is able to show anticipation for their like or dislike of something

Level 3

This individual is able to communicate, detail, qualify, specify and/or indicate opinions

Level 4

* This is adapted from the Kidderminster Curriculum for Children and Adults with Profound Multiple Learning Difficulty (Jones, 1994, National Portage Association).

Facial signs

Ring the words that best fit the facial appearance. Add your own words if you want.

Appearance when content Appearance when distressedWhat to do

Passive Laugh Smile

Frown Grimace Startled

In your own words:

Passive Laugh Smile

Frown Grimace Startled

In your own words:

Jaw or tongue movement

Ring the words that best fit the jaw or tongue movement. Add your own words if you want.

Movement when content Movement when distressedWhat to do

Relaxed Drooping Grinding

Biting Rigid Shaking

In your own words:

Relaxed Drooping Grinding

Biting Rigid Shaking

In your own words:

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Appendix 1

Apearance of eyes

Ring the words that best fit the appearance of the eyes. Add your own words if you want.

Appearance when content Appearance when distressedWhat to do

Good eye contact Little eye contact

Avoiding eye contact Closed eyes

Staring Sleepy eyes

‘Smiling’ Winking Vacant

Tears Dilated pupils

In your own words:

Good eye contact Little eye contact

Avoiding eye contact Closed eyes

Staring Sleepy eyes

‘Smiling’ Winking Vacant

Tears Dilated pupils

In your own words:

Body observations: skin appearance

Ring the words that best fit the appearance of the skin. Add your own words if you want.

Appearance when content Appearance when distressedWhat to do

Normal Pale Flushed

Sweaty Clammy

In your own words:

Normal Pale Flushed

Sweaty Clammy

In your own words:

Vocal sounds (NB. The sounds that a person makes are not always linked to their feelings)

Ring the words that best fit the sounds.Write down commonly used sounds (write it as it sounds, e.g. ‘tizzz’, ‘eeiow’, ‘tetetetete’).

Sounds when content Sounds when distressedWhat to do

Volume: high medium low

Pitch: high medium low

Duration: high medium low

Description of sounds/vocalisation:

Cry out Wail Scream

Laugh Groan/moan

Shout Gurgle

In your own words:

Volume: high medium low

Pitch: high medium low

Duration: high medium low

Description of sounds/vocalisation:

Cry out Wail Scream

Laugh Groan/moan

Shout Gurgle

In your own words:

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Appendix 1

Speech

Write down commonly used words and phrases. If no words are spoken, write NONE.

Words when content Words when distressedWhat to do

Clear Stutters Slurred

Unclear Muttering Fast

Slow Loud Soft

Whisper Other, e.g. swearing:

Clear Stutters Slurred

Unclear Muttering Fast

Slow Loud Soft

Whisper Other, e.g. swearing:

Ring the words which best describe the speech.

Habits and mannerisms

Write down the habits or mannerisms, e.g. ‘Rocks when sitting’.

Habits and mannerisms when content

Habits and mannerisms when distressed

What to do

Close with strangers

Close only if known

No one allowed close

Withdraws if touched

Close with strangers

Close only if known

No one allowed close

Withdraws if touched

Ring the statements which best describe how comfortable this person is with other people being physically close by.

Write down any special comforters, possessions or toys this person prefers.

Body posture

Observations when content Observations when distressedWhat to do

Normal Rigid Floppy

Jerky Slumped Restless

Tense Still

Able to adjust position

Leans to side Poor head control

Way of walking: Normal/Abnormal

Other:

Normal Rigid Floppy

Jerky Slumped Restless

Tense Still

Able to adjust position

Leans to side Poor head control

Way of walking: Normal/Abnormal

Other:

Ring the words that best describe how this person sits and stands.

Appendix 1

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Body observations: other

Describe the pulse, breathing, sleep, appetite and usual eating pattern, e.g. eats very quickly, takes a long time with main course, eats puddings quickly, picky.

Observations when content Observations when distressedWhat to do

Pulse:

Breathing:

Sleep:

Appetite:

Eating pattern:

Pulse:

Breathing:

Sleep:

Appetite:

Eating pattern:

Information and instructions

DisDAT is:

Intended to help identify distress cues in individuals who have severely limited communication.

Designed to describe an individual’s usual content cues, thus enabling distress cues to be identified more clearly.

NOT a scoring tool. It documents what many carers have done instinctively for many years, thus providing a record against which subtle changes can be compared.

Only the first step. Once distress has been identified the usual clinical decisions have to be made by professionals.

Meant to help you and the individual in your care. It gives you more confidence in the observation skills you already have, which in turn will give you more confidence when meeting other carers.

When to use DisDATWhen the carer believes the individual is NOT distressed

The use of DisDAT is optional, but it can be used as a:

• baseline assessment document

• transfer document for other carers.

When the carer believes the individual IS distressed

If DisDAT has already been completed it can be used to compare present signs and behaviours with previous observations documented on DisDAT. It then serves as a baseline to monitor change.

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Appendix 1

If DisDAT has not been completed:

a) When the person is well known to a carer, DisDAT can be used to document previous signs and behaviours that show the individual is content, and to compare these with current observations.

b) When the person is new to a carer, or the distress is new, DisDAT can be used to document present signs and behaviours to act as a baseline to monitor change.

How to use DisDAT1. Observe the individual when content and when distressed – document this

on the inside pages. Anyone who cares for them can do this.

2. Observe the context in which distress is occurring.

3. Use the clinical decision distress checklist on the next page to assess the possible cause.

4. Treat or manage the most likely cause of the distress.

5. The monitoring sheet is a separate sheet, which will help if you want to observe a pattern of distress or see how the distress changes over time. Its use is optional. There are three types to choose from on the website – use whichever suits you best.

6. The goal is a reduction in the number or severity of distress signs and behaviours.

Remember• Most information comes from several carers together.

• The assessment form need not be completed all at once and may take a period of time.

• Reassessment is essential as the needs of the individual may change due to improvement or deterioration.

• Distress can be emotional, physical or psychological. What is a minor issue for one person can be major to another.

• If signs are recognised early then suitable interventions can be put in place to avoid a crisis.

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Appendix 1

Clinical decision distress checklist Use this to help decide the cause of the distress.

Is the new sign or behaviour: • Repeated rapidly?

Consider pleuritic pain (in time with breathing)

Consider colic (comes and goes every few minutes)

Consider repetitive movement due to boredom or fear

• Associated with breathing?

Consider infection, chronic obstructive pulmonary disease (COPD), pleural effusion or tumour

• Worsened or precipitated by movement?

Consider movement-related pains

• Related to eating?

Consider food refusal because of illness, fear or depression

Consider food refusal because of swallowing problems

Consider upper gastrointestinal problems (e.g. oral hygiene problems, peptic ulcer, dyspepsia) or abdominal problems

• Related to a specific situation?

Consider frightening or painful situations

• Associated with vomiting?

Consider causes of nausea and vomiting

• Associated with elimination (urine or faecal)?

Consider urinary problems (e.g. infection, retention)

Consider gastrointestinal problems (e.g. diarrhoea, constipation)

• Present in a position or situation which is normally comfortable?

Consider anxiety, depression, pain at rest (e.g. colic, neuralgia), infection or nausea

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Appendix 1

Further readingRegnard C, Matthews D, Gibson L, Clarke C, Watson B. Difficulties in identifying distress and its causes in people with severe communication problems. International Journal of Palliative Nursing, 2003; 9(3)173–6.

Regnard C, Reynolds J, Watson B, Matthews D, Gibson L, Clarke C. Understanding distress in people with severe communication difficulties: developing and assessing the Disability Distress Assessment Tool (DisDAT). J Intellect Disability res. 2007; 51(4): 277–292

Additional information

If you require any help or further information regarding DisDAT please contact:

Lynn Gibson 01670 394 260

Dorothy Matthews 01670 394 808

Dr. Claud Regnard 0191 285 0063 or email on claudregnard@stoswaldsuk.org

For more information see www.disdat.co.uk

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Appendix 2

Appendix 2: Activities for trainingActivity 1 – Identifying foods and drinks containing sugarAim: To encourage participants to think about the foods and drinks that

contain sugar.

Outcome: Participants will be aware of food and drinks that contain sugar.

Instructions• You will need flipchart paper and marker pens.

• Depending on the group size, either split into smaller groups (giving each group their own flipchart paper) or work as one big group.

• Ask the group/s to think of food and drinks that contain sugar and write these on the flipchart paper (if there is only one group, the trainer can write).

• Ask the group/s to think of food and drinks that are sugar-free and write these on the flipchart paper.

Suggested answersWhat types of food and drinks should be restricted to mealtimes?

• Fizzy drinks and juice drinks

• Sweets and biscuits

• Dried fruit

• Jam

• Cakes, pastries and puddings

• Ice cream

What types of food and drinks can be eaten as snacks between mealtimes?

• Fresh fruit and vegetables

• Bread

• Toast

• Naan bread

• Chapatti

• Poppadoms

• Nuts and seeds

• Oatcakes

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Appendix 2

• Cheese

• Natural yoghurt

• Milk

• Water

• Tea or coffee (without sugar or honey)

Discussion points• Were you surprised to find out that some of these products contained sugar?

• Which product were you most surprised about?

• Will this information change what you eat as a snack between meals?

Activity 2 – Reducing the amount and frequency of sugarAim: To encourage participants to think of ways they could reduce the amount and frequency of sugar in a person’s diet.

Outcome: Participants will have an awareness of ways they could reduce the amount and frequency of sugar in a person’s diet.

Instructions• Organise trainees into small groups of around three to five people.

• Ask them to work in their groups to think about ways to reduce the amount and frequency of sugar in a person’s diet.

• After discussion, let each group report back its ideas.

Suggested answers• Reduce the number of food and drinks containing sugar.

• Choose water or milk instead of sugary drinks.

• Try a currant bun or scone with a low-fat spread instead of cakes or biscuits.

• Try to slowly reduce the amount of sugar you add to your hot drinks or breakfast cereal, eventually stopping altogether.

Additional information

You can find more information in the Oral Health and Nutrition Guidance for Professionals published by NHS Health Scotland, and the Eatwell Guide. See page 89 for further details on each.

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Appendix 2

• Have a low-fat spread, sliced banana, or low-fat cream cheese on toast instead of jam, marmalade, syrup, treacle or honey.

• Choose foods with less added sugar or go for the low-sugar version (you can check food labels to help you choose).

• Try halving the sugar you use in your recipes. It works for most things except jam, meringues and ice cream.

• Choose tins of fruit in juice rather than syrup.

• Choose wholegrain breakfast cereals rather than those coated with sugar or honey.

Discussion points• Do you think any of these suggestions would work for a person you care for?

• What might make it difficult to implement these changes?

Trainer’s noteSome people may be on a high-calorie diet or prescribed supplements and snacks. This may increase both the amount of sugar in their diet and the frequency of its consumption. As they are at higher risk of tooth decay, they may need more intensive mouth care. This could mean using a high-strength fluoride toothpaste, or regular use of fluoride mouthwash on instruction from the dentist. An alternative to using high-strength fluoride toothpaste may be to keep using normal toothpaste (1350–1500 ppm fluoride) but to brush more often.

Activity 3 – Cleaning natural teeth and denturesAim: To increase practical knowledge of carrying out oral care.

Outcome: Participants will have an awareness of how to effectively clean natural teeth and dentures.

Instructions• Organise trainees into small groups of around three to five people.

• Ask them to identify the steps involved in cleaning natural teeth, and then the steps involved in cleaning dentures.

• After discussion, let each group report back its ideas.

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Appendix 2

Suggested answers: Natural teeth cleaning• Let the person know what you are going to do, and make sure they are in a

comfortable position.

• Use a medium textured small-headed brush and toothpaste containing ideally 1350–1500 ppm fluoride.

• The brush should be dry so that the fluoride is not diluted.

• Just a pea-sized amount of toothpaste is needed.

• The aim is to brush every surface of every tooth and the gums too.

• Starting with either the lower or upper jaw, place the brush on the outer surface of the back teeth and gums. Work around the outside surfaces first, gently scrubbing each tooth for a count of six.

• When you finish the last back tooth, use the same method for the inside surfaces of all teeth.

• Brush the chewing surfaces.

• Start again on the other jaw, repeating the above method.

• Even if the gums bleed slightly, continue to brush them, as only continued brushing will improve gum health.

• It is recommended that everyone should spit at the end of brushing, but not rinse. This leaves a coating of fluoride toothpaste which continues to protect teeth.

Suggested answers: Denture cleaning• Use mild liquid soap and water or denture cream to clean dentures.

• Brush dentures over a bowl or sink containing water so the dentures do not get broken if they are dropped.

• Scrub off food debris, plaque and any fixative (adhesive).

• Hold the lower denture in the middle while cleaning, as holding it at either end applies force and may cause it to break.

• Plastic dentures should be soaked in disinfecting fluid daily for 20 mins, thoroughly rinsed, then soaked in water overnight.

• Metal-based dentures should be soaked in chlorhexidine for 20 mins daily. The dentures should then be thoroughly rinsed and soaked in water overnight.

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Appendix 2

Activity 4 – Oral health paperworkAim: To give participants the opportunity to develop a risk assessment, care plan and daily documentation chart for highlighted case studies.

Outcome: Participants will have experience of completing paperwork for the types of people they work with or care for.

Instructions• Participants should pair up.

• Each group should be given one of the four case studies in Appendix 3 and a set of paperwork.

• They should be asked to read through the case study and complete a risk assessment and a care plan. They should discuss the usefulness of the daily documentation chart.

• Once all groups have completed the paperwork, ask each group to feed back on:

• what risks they identified with their case study

• what actions they noted on the care plan

• any additional notes

• how useful and realistic they feel the daily documentation chart would be.

Discussion points• Is this similar to any risk assessment paperwork you already use?

• Did you find it simple to use?

• Do you think it would be useful to complete this paperwork for the person you care for?

Trainer’s noteLet participants know that they should put their own names in the ‘Support Worker’ box when completing paperwork.

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Appendix 3

Appendix 3: Case studiesThese case studies are fictitious and not associated with any real people.

Case study 1

Group versionBackground

Alison Black, born 04/07/1967, has been in the care home for one year after previously staying with her mum. She is not registered with a dentist at the moment.

She has mild learning disabilities but is very attention seeking and will try to draw attention to herself while carers are trying to help other residents. She is also very demanding.

Oral health

She has her own teeth and no dentures. She brushes her own teeth with an electric toothbrush but needs a lot of prompting. She doesn’t require assistance with setting up her toothbrush and toothpaste. Her poor oral health sometimes causes her gums to bleed and her teeth are sensitive.

Other factors

She regularly complains about toothache but often changes her mind when told she can’t do an activity (e.g. shopping) because of this. Carers have recognised that this can sometimes be attention seeking behaviour.

She is on sugar-based oral medicine for her epilepsy. She takes this twice daily and carers note that it tends to stick in her mouth.

As a group, complete an oral health risk assessment and a care plan, and discuss the daily documentation chart for Alison.

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Appendix 3

Trainer’s versionBelow are discussion points that the group should pick out of the case study. Use these to encourage discussion and to ensure correct completion of the oral health risk assessment and care plan.

Background – discussion prompts and answers

Keep a record on the original risk assessment, develop an oral care plan and arrange dental registration for Alison. Use appropriate communication techniques to engage with Alison.

Oral health – discussion prompts and answers

Record that Alison has her own teeth on the risk assessment and care plan. Think – are her bleeding gums and sensitive teeth being addressed? How do Alison’s carers know her teeth are sensitive? What signs have they noticed? Seek dental advice for bleeding gums and tooth sensitivity.

Other factors – discussion prompts and answers

Alison may genuinely be in pain, so make an immediate referral to a dentist.

Record Alison’s medication on her risk assessment. Consider using a high-strength fluoride toothpaste or increasing the number of times a day she brushes her teeth, rinsing with water after medication.

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Appendix 3

Case study 2

Group versionBackground

Susan Anderson, born 02/07/1989, has severe learning disabilities and has very challenging behaviour coupled with mental health issues. When in a low mood she tends to say no to everything. Since moving into the home on 2 January she has been quite distressed and low. She is not registered with a dentist and it is unknown when she last had a check-up.

Oral health

She has her own teeth. She will only use strawberry flavoured toothpaste. She tends to say no to toothbrushing when asked, but if the carer explains each step of toothbrushing, e.g. ‘Do you want to open your mouth now Susan?’ she is happy to comply. Toys are also used to encourage her to have her teeth brushed. For example, the carer will say ‘Will I just brush Mickey’s teeth then?’ if she says no. Susan will then respond ‘No! Brush Susan’s!’ She will sometimes hit herself when carers try to brush her teeth. Staff have noticed black patches on her teeth but these don’t seem to be causing her any pain.

Other factors

She does not smoke and has no issues with eating food. She is not on any medication with oral side effects. She would be unable to go to a dental surgery due to her severe learning disability.

As a group, complete an oral health risk assessment and a care plan, and discuss the daily documentation chart for Susan.

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Appendix 3

Trainer’s versionBelow are discussion points that the group should pick out of the case study. Use these to encourage discussion and to ensure correct completion of the oral health risk assessment and care plan.

Background – discussion prompts and answers

Consider suitable communication strategies before engagement with Susan. Record on the risk assessment that she is not registered with a dentist and arrange for registration as a priority. Develop an oral care plan.

Oral health – discussion prompts and answers

Record that Susan has her own teeth. Strawberry toothpaste may be better than nothing at all – check the fluoride content. It is good that the carers are getting compliance. Prompts are a good strategy with Susan. Susan may be hitting herself as she is in pain and can’t communicate this. Consider another carer or a different approach. Document in daily oral care the idea that Susan may be in pain and unable to communicate this.

Other factors – discussion prompts and answers

Record on the risk assessment form that Susan doesn’t smoke and has no eating issues. Why is she unable to attend a dental surgery? Seek dental advice on this. Consider issues of consent. Consider talking to Susan’s family about a suitable dental environment for Susan.

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Appendix 3

Case study 3

Group versionBackground

David Douglas, born 05/06/1958, has had a stroke and as a result can only use one hand effectively. He lives alone, with paid carers coming into his home.

He is now unable to communicate verbally. He only communicates through noises and pointing with his eyes. He has recently started to hit his head off the bedrail and his wheelchair and to constantly put his ‘good’ hand in his mouth. He can eat finger food himself but staff need to feed him other food. He has recently become less enthusiastic about eating. He is registered with The Dental Practice, 1 High Road, Sometown, and the dentist last visited on 23 May this year.

Oral health

David does not have any teeth and will not let anyone brush the soft tissues in his mouth. Staff tend to try to have a look in his mouth when they are feeding him. He also refuses to let the dentist look in his mouth so when the dentist visits they just try to have a look from a distance.

Other factors

David does not smoke now, although he used to smoke 20 cigarettes a day. David is on medication which can lead to a dry mouth. He is not on any special diet and does not have any problems swallowing. Occasionally David refuses to drink his coffee, but will be happy to drink a cold drink. Staff are wondering if there is a problem with his mouth.

As a group, complete an oral health risk assessment and a care plan, and discuss the daily documentation chart for David.

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Appendix 3

Trainer’s versionBelow are discussion points that the group should pick out of the case study. Use these to encourage discussion and to ensure correct completion of the oral health risk assessment and care plan.

Background – discussion prompts and answers

Complete the risk assessment and daily oral care plan. Think about pain – are David’s behaviours because he is unable to communicate pain?

Consider issues of consent.

Oral health – discussion prompts and answers

Record on the risk assessment that David has no teeth. Seek dental advice on the best techniques for cleaning soft tissues. There is a need for a proper dental examination.

Other factors – discussion prompts and answers

Record previous smoking history on the risk assessment. Refer to above about hitting his head. There is a need to seek dental advice to exclude pain in his mouth.

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Appendix 3

Case study 4

Group versionBackground

Archie McDonald, born 13/12/1965, has his own living space within supported accommodation. He moved in on 12 June when his dad died. He has advanced multiple sclerosis and is PEG fed. His speech is difficult to understand and he uses a computer to communicate. He has his own natural teeth but has an upper partial denture which he has had for 10 years. He is registered with his own dentist, at The Dental Practice in Crescent Street in Thistleton, and last went to the dentist about two months ago.

Oral health

Archie has to be prompted to brush his teeth but is capable of brushing them himself with this encouragement. He also has to be prompted to clean his denture. When you began to care for him, you noticed that the gum part of his denture was bright white. You have also noticed his palate is very red underneath his denture and this is affecting his eating. He is willing to go to the dentist but sometimes becomes anxious in the days before the visit.

Other factors

He is a non-smoker and isn’t on any medication with oral side effects.

As a group, complete an oral health risk assessment and a care plan, and discuss the daily documentation chart for Archie.

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Appendix 3

Trainer’s versionBelow are discussion points that the group should pick out of the case study. Use these to encourage discussion and to ensure correct completion of the oral health risk assessment and care plan.

Background – discussion prompts and answers

There is a need for someone who knows Archie to help with communication.

Oral health – discussion prompts and answers

Record that Archie has his natural teeth and a lower denture on the risk assessment. Dentures can be marked by the lab or in a care home. Seek dental advice on this. Encourage Archie to brush his teeth himself, with support if needed. How are the dentures cleaned? They should be soaked in sodium hypochlorite solution after brushing. Does he need a new denture? Has this been discussed with the dentist? The red palate suggests that Archie has a fungal infection. What treatment, if any, is he receiving for this?

Other factors – discussion prompts and answers

Record Archie’s non-smoker status on the risk assessment.

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Appendix 4

Appendix 4: Useful contacts, resources and informationCaring for SmilesThis is Scotland’s national oral health promotion, training and support programme, which aims to improve the oral health of older people, particularly those living in care homes. Go to the Scottish Dental home page and search for ‘caring for smiles’ for access to resources. www.scottishdental.org

The Eatwell GuideThe Eatwell Guide helps us eat a healthy, balanced diet with plenty of fruit, vegetables and starchy carbohydrates plus some dairy, meat, fish, pulses and other kinds of protein. www.foodstandards.gov.scot/consumers/healthy-eating/eatwell

Oral Health and Nutrition Guidance for ProfessionalsThis provides consistent, evidence-based guidance on oral health and nutrition for the whole population. www.healthscotland.scot/publications/oral-health-and-nutrition-guidance

NHS InformNHS Inform is Scotland’s health information service. NHS Inform has pages about oral health. From the home page click on ‘Healthy living’ and then ‘Dental health’ for more information. www.nhsinform.scot

Palliative Care GuidelinesIn palliative and end-of-life care, mouth care should be carried out regularly to ensure the person is kept as comfortable as possible. The NHS has published guidelines on mouth care in palliative care. www.palliativecareguidelines.scot.nhs.uk

The Scientific Basis of Oral Health EducationThis provides more detailed information and advice on the main aspects of oral health. Levine RS, Stillman-Lowe CR. BDJ Books: London; 2009.

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