Mouth Care Matters Mouth Care Matters A guide for hospital healthcare professionals Developing people for health and healthcare www.hee.nhs.uk Version control Version: V12 Date ratified: 11 November 2016 Name and title of author Mili Doshi, Consultant in special care dentistry Date issued 11 November 2016 Review date November 2017 © 2016 Mouth Care Matters Contents A guide for health care professionals 1 Introduction 6 7 Dental decay (caries) 30 1.1 What is Mouth Care Matters in hospitals? 7 7.1 What is dental decay (caries)? 31 1.2 The Mouth Care Matters training programme 8 7.2 Signs of dental decay 31 1.3 Who is Mouth Care Matters training for? 8 7.3 Symptoms of dental decay 31 1.4 Mouth Care Matters team 8 7.4 Causes of dental decay 31 7.5 Prevention of dental decay 32 2 Why do we need Mouth Care Matters training? 10 7.6 Management of dental decay in hospitalised patients 32 2.1 What is the impact of hospitalisation on oral health? 11 8 Diet and oral health 33 2.2 We are a changing population 11 8.1 Effects of sugar in teeth 34 2.3 Our mouths are changing 11 8.2 Safe snacks 34 2.4 We are taking more medication 11 8.3 Sugar and medication 34 2.5 What are the barriers to providing good mouth 9 Fluoride 35 care in hospitals? 11 9.1 What is fluoride? 36 2.6 References 12 9.2 How does fluoride work? 36 3 Why is oral health important for 9.3 How much fluoride is enough? 36 hospitalised patients? 14 9.4 References 36 3.1 Definition of oral health 15 3.2 Oral hygiene and oral health 15 10 Tooth surface loss 37 10.1 What is tooth surface loss? 38 3.3 References 15 10.2 Signs of tooth surface loss 38 4 Oral health and general health 17 10.3 Symptoms of tooth surface loss 38 4.1 Oral health links to systemic disease 18 10.4 Tooth erosion 38 4.2 Hospital-acquired infections linked 10.5 Management of tooth erosion in hospitalised to poor oral hygiene 19 patients 38 4.3 Links to general health and 10.6 Tooth abrasion 39 systemic disease 19 10.7 Management of tooth abrasion in hospitalised 4.4 References 19 patients 39 5 A healthy mouth 21 10.8 Tooth attrition 40 5.1 Why ‘Mouth Care Matters’ and not 10.9 Management of tooth attrition in hospitalised ‘Dental Care Matters’? 22 patients 40 5.2 What does a healthy mouth look like? 22 11 Periodontal (gum) disease 41 5.3 What could an unhealthy mouth look like? 23 11.1 Definition of periodontal (gum) disease 42 5.4 When to seek medical/dental advice 24 11.2 Causes of gum disease 43 5.5 References 24 11.3 Signs of gum disease 43 6 Dry mouth (xerostomia) 25 11.4 Symptoms of gum disease 43 6.1 What is a dry mouth? 26 11.5 Management of gum disease in hospital 43 6.2 What are the functions of saliva? 26 12 Oral thrush (candida/fungal infection) 44 6.3 What are the signs and symptoms of 12.1 What is oral thrush? 45 a dry mouth? 26 12.2 Causes of oral thrush 45 6.4 What are the causes of a dry mouth? 26 12.3 Signs of oral thrush 45 6.5 What is the impact of a dry mouth on hospitalised patients? 26 12.4 Symptoms of oral thrush 45 6.6 Prevention 27 12.5 Management of oral thrush in hospitalised patients 46 6.7 Management of a dry mouth for hospitalised patients 27 12.6 Antifungal medication 46 6.8 Saliva substitutes/moisturising agents 28 12.7 References 46 6.9 Mouth audit at East Surrey Hospital 29 6.10 References 29 Contents 13 Angular cheilitis 47 19 Having the ‘right tools’ for mouth care 13.1 What is angular cheilitis? 48 and assessment on the wards 67 13.2 Causes of angular cheilitis 48 19.1 Pen torches 68 13.3 Signs of angular cheilitis 48 19.2 Toothbrushes 68 13.4 Symptoms of angular cheilitis 48 19.3 Toothpastes 70 13.5 Management of angular cheilitis in hospital 19.4 Foam swabs 70 patients 48 19.5 Finger guard 72 14 Mouth ulcers 49 19.6 Prescribed/on the advice of a dentist/doctor 72 14.1 What is a mouth ulcer? 50 19.7 References 72 14.2 Causes of mouth ulcers 50 20 Recording mouth care for hospitalised 14.3 Signs of a mouth ulcer 50 patients – The Mouth Care Pack 73 14.4 Symptoms of a mouth ulcer 50 20.1 Why do we need to record mouth care? 74 14.5 Management of mouth ulcers in hospital 51 20.2 The tool - Mouth Care Pack 74 20.3 Guide for completing the Mouth 15 Excessive drooling 53 Care Pack 74 15.1 Why do some patients drool? 54 20.4 Completing the mouth care screening sheet 75 15.2 Signs of drooling 54 20.5 Notes on the mouth care screening sheet 75 15.3 Symptoms of drooling 54 20.6 Level of support 75 15.4 Management of drooling in 20.7 Mouth care assessment (middle pages of the hospitalised patients 54 mouth care pack) 77 16 Mucositis 55 20.8 Daily recording sheet 79 16.1 What is mucositis? 56 20.9 References 79 16.2 Signs of mucositis 56 21 Assisting patients with mouth care 81 16.3 Symptoms of mucositis 56 21.1 How to distinguish between independent and 16.4 Management of mucositis in dependent patients? 82 hospitalised patients 56 21.2 Different types of assistance 82 17 Oral cancer 57 21.3 Cross infection control 83 17.1 What is oral cancer? 58 21.4 Key messages in steps 84 17.2 What are the signs and symptoms of 22 Denture care 85 oral cancer? 58 22.1 Changes in denture demographics 86 17.3 Management of suspected oral cancer in hospital 58 22.2 Types of dentures 86 22.3 Importance of denture hygiene 87 18 Patients with increased oral health risk factors 59 22.4 Denture fixative 87 18.1 Why are some patients more at risk from mouth 22.5 Removing and replacing dentures in the mouth 87 care problems? 60 22.6 Lost dentures 87 18.2 Signs of mouth related problems in vulnerable 22.7 Cleaning dentures 88 patients 60 22.8 The denture sunflower 90 18.3 Dementia and oral health 60 23 Dental referrals 91 18.4 Mental Capacity Act 61 23.1 Urgent and non-urgent referrals 92 18.5 Learning disabilities and oral health 62 18.6 Mental health conditions and oral health 62 24 Drugs that cause dry mouth (xerostomia) 93 18.7 Intensive care – ventilated patients and oral health 62 25 MOUTHS 95 18.8 Head and neck cancer treatment and 25.1 What is MOUTHS? 96 oral health 63 26 Contact 97 18.9 Stroke, dysphagia and oral health 63 18.10 Physical disability and oral health 63 18.11 End of life care and oral health 64 18.12 References 64 1 Introduction Key messages • MCM is a training initiative to improve the oral health of hospitalised patients • MCM training comes in various formats • MCM training is not just for nurses but a range of health care professionals Introduction 1.1 What is Mouth Care Matters in hospitals? observations of mouth care being carried out on patients on the wards. Mouth Care Matters (MCM) is a training initiative aimed at improving the oral health (health of the mouth) of Mouth Care Matters is based on four key themes, hospital hospitalised adult patients in Kent, Surrey and Sussex. staff require the: This guide complements the Mouth Care Matters • Knowledge of the importance of mouth care and training that is currently being delivered in hospitals. The good oral health and the links to general health information to the best of our knowledge, is up-to-date and well-being and evidence-based. The programme was developed and piloted at East Surrey • Skills gained through training on how to carry out Hospital, an acute hospital with approximately 650 beds. mouth care and assessment of the mouth From a comprehensive review of the current literature, we • ‘Tools’ needed to provide good mouth care believe the findings at East Surrey Hospital, with regards to mouth care, are representative of hospitals up and down • Support when necessary from doctors/dentists/ the country. For this reason this guide includes findings mouth care team from focus groups, clinical audits, patient cases and direct About ‘Mouth Care Matters’ posters Poster to help identify a healthy & unhealthy mouth 7 A guide for health care professionals 1.2 The Mouth Care Matters training 1.4 Mouth Care Matters team programme As part of the Mouth Care Matters training programme, Factoring in time for additional training for busy health Surrey and Sussex Health Care Trust recruited a mouth care care professionals can be difficult, therefore MCM training team. This team is responsible for: comes in various formats and includes: • Ward-based training • Small group classroom teaching sessions • Classroom training • Ward-based, hands-on training • Supporting staff and carers with mouth care in challenging situations • Sessions tailored to specific groups, for example the speech and language team, palliative care, • Liaising when urgent dental referrals are needed chemotherapy, oncology, doctors, dieticians and during an inpatient stay pharmaceutical team • Signposting patients to appropriate dental services on discharge • E-Learning • Supporting the hospital with mouth care policies MCM guide • and audit • MCM resources (posters, newsletters etc.) • Mouth Care Matter promotional and social media work • MCM website Mouth Care Matters supports the need for every hospital to have a dedicated mouth care lead.