GUIDELINES AND AUDIT IMPLEMENTATION NETWORK

Oral Care Training Package

February 2013 Aims and Objectives

Aim To promote an awareness of issues in relation to care with dependent patients

Objectives • Appreciate the need for good • Be aware of the common oral conditions and how to manage them • Be familiar with oral assessment tool and how to complete it Why…?

• or trauma to the mouth can exacerbate the patient’s general medical condition and reduce their quality of life (White, 2000).

• Lack of mouth care provision is a feature of patient care complaints (Granger, 2007).

• Oral Health of elderly 65+ adults in private residential/nursing homes is SIGNIFICANTLY worse than those living in the community. (National Diet & Nutrition Survey 1998) Aim of good mouth care

The principal objectives of mouth care for the patient who is very dependent or ill are to: • Keep the lining of the mouth and clean & soft • Keep the moist • Prevent • Alleviate halitosis & by removing plaque & debris • Promote patient comfort & quality of life (Hewett, 2006) Why is Oral Care Important

• Oral health problems – Gum disease, dental decay, bad breath • Speech, physical expression, swallowing, taste • Systemic – Shown to be contributory factor to aspiration pneumonia • Nutritional status • PEG feed – Always refer to dentist – Refer to CREST guidelines

Infection Control

• Refer to Infection Control Policy • Wash & dry hands • Use appropriate PPE i.e. gloves,aprons,masks & goggles • Use Non latex gloves if appropriate • All equipment identified with patients name • After use toothbrushes & denture brushes - • should be rinsed in water • excess shaken off • stored in the open to dry

Care of teeth

• Wear Personal protective equipment (gloves, aprons) • Small head, medium textured toothbrush • If mouth particularly sore, soft baby brush • Remove before cleaning natural teeth • Small (smear or pea sized) amount of adult fluoride toothpaste at least 1450 ppm or above e.g. Duraphat 2800

For Elderly population in Residential Care in areas with low levels of fluoride in drinking water, who are assessed as being at increased risk of dental caries , toothbrushing carried out twice daily with a 2,800 ppm fluoride paste, following the manufacturers instructions regarding quantity, is likely to give improved caries control over standard toothpaste while avoiding any risk of toxicity.

(Innes N , Evans D . Caries prevention for older people in residential care homes .Evidence Based 2009; 10: 83-84) • Clean all surfaces of teeth paying particular attention to the tooth gum margin

• Spit out excess do not rinse with water

• Replace brush every 3 months or sooner if bristles become worn

• Patients with difficulty swallowing use less paste or non foaming (non SLS)

• If the patients bleed continue to brush. More frequent episodes of mouth care may be required. If no improvement, contact a dentist for further advice

• Gently clean the tongue, and cheek mucosa with a soft toothbrush or a finger wrapped in gauze

• Foam swabs not recommended due to choking hazard

• Lemon and glycerine swabs should never be used

• Record all mouth care interventions in the patients records for reference

• If a patient becomes critically ill, enters a high dependency ward or requires intubation, their oral hygiene programme should be reassessed

Oral Hygiene in the presence of Dysphagia

• Patients should be in an upright or semi upright position • Ideally two carers • Suction should be available • Any dentures should be removed • Toothbrushing should be undertaken when the carer is in front of the patient – access and vision is improved.

Dietary Supplements

• Food supplements pose challenges to oral health in patients with natural teeth due to their high sugar content.

• Essential that there is close co-operation between medical and nursing staff, care staff, dietitians and dentists.

• Give dietary supplements at mealtimes when possible and not last thing at night, unless clinically directed otherwise.

Care of Dentures

• Thoroughly clean at least once per day (preferably at night) • Remove partial & complete dentures for cleaning • Clean & check lining of mouth separately • Rinse under running water between meals

• Brush dentures immersed in water

• Brush with patients own toothbrush, denture or nail brush

• Use liquid soap, denture cleaning paste

• Rinse dentures before reinserting

• Dentures should be removed and soaked overnight in a commercial cleaning solution

• Soaking alone will not clean dentures and thorough brushing is essential

• Ideally dentures should be clearly marked with patients name

• Store dentures in container clearly marked with patients name

Care of the rest of mouth

• Roof of mouth, gum ridges & tongue should be gently cleaned daily with soft toothbrush

• Ideally mouth should be cleaned after every meal

• Oil based products such as petroleum jelly not recommended for protection (risk of aspiration) use water based products instead e.g. KY Jelly Oral Medical Conditions

• Oral Thrush • Angular / • Mouth ulcers • Bad Breath/Halitosis • Dry Mouth/ • Coated/Hairy Tongue • Oral Thrush (Oral )

Caused by a called ‘’ • Signs & Symptoms – White spots in the mouth & on tongue – May join together to form larger spots or plaques – If wiped off may be red & raw – May be red / inflamed under dentures – Mild condition may be painless – May have smooth red tongue – May lead to dysphagia

Management

• Keep mouth as clean as possible

• Denture hygiene extremely important – Soak in sodium hypochlorite/ solution

• Anti-fungal treatment may be required

• Consider referral to dentist if symptoms persist despite treatment

Angular Cheilitis/Stomatitis

Inflamed cracks at one or both corners of the mouth Causes: • Candida •

Signs & Symptoms • Mild at the angles of the mouth • Severe cases – may bleed or crust over

Management

• Continue with good oral and denture care • If Candida involved use topical anti-fungals • If bacteria are involved, treat with Fuscidic Acid Cream/Ointment • Where both Bacteria and Candida involved, Oral Gel will treat both • Chlorhexidine has good anti-fungal and anti-bacterial properties to clean mouth/dentures

Mouth Ulcers

Painful sore on the lips, cheeks, tongue or gums Causes: • Trauma • Poor nutrition • Drugs • Blood disorders • Infection • Neoplasm • Usually red or yellow in colour • Pain especially when eating / drinking

Management

• Treat any reversible causes • Keep the mouth and dentures clean • Avoid foods that are spicy, acidic, salty or particularly hot or cold

Consider treating with • Warm saline Mouthwash • Antiseptic Mouthwash • Adcortyl in Orabase® • Corlan Pellets® • Local Anaesthetics

If the ulcer doesn’t heal within two weeks refer to dentist

Bad Breath (Halitosis)

Causes • Build up of bacteria in the mouth, resulting from food debris, plaque or gum disease • Poor dental hygiene (90% of cases) • Morning bad breath • Food and Drink • Medicines • • Medical Causes Management

• Treat any reversible causes • Improve oral and denture care

Dry Mouth (Xerostomia)

Persistent dry mouth caused by reduced salvia Causes: • Drugs • Candida • Dehydration • Anxiety • • Radiotherapy • Oxygen

Management

• Treat underlying cause if possible • Good oral and denture hygiene • Sipping cold water • Dietary Advice • Artificial Substitutes • Salivary Stimulants • Medication

Coated/Hairy Tongue

Coated Tongue – Accumulation of keratin, harmless but unpleasant condition – Overgrowth of certain pigment forming bacteria Causes: – Smoking – Poor oral hygiene – Use of certain – Chronic use of antacids and some types of mouthwash

Management

• Correct any reversible causes • Good oral and denture care which may include the use of a tongue scraper, to remove dead cells • Consider use of appropriate mouthwash To remove discolouration – Use a tongue scraper – Brush the tongue with a toothbrush twice a day – Rinse mouth and brush the tongue with diluted hydrogen peroxide (one part peroxide to five parts water). – Rinse with water afterwards.

Herpes Simplex (Cold Sores)

Viral infection of the mouth

Common in immunocompromised patients

Cause: Herpes Simplex Virus

Management

Good oral & denture care

• Be aware of infection risk • Acyclovir – topical /systemic

Thanks for listening

Any questions ??