Oral health of older people

Question 1

What age are people expected to live now?

Answer 1

Beyond 60 in low, middle & high income countries

Question 2

What is healthy ageing?

Answer 2

Process of developing and maintaining the functional ability that enables well- being in older age

Question 3

What are the majority of health conditions experienced by older people due to?

Answer 3

Non-communicable diseases

Question 4

What can ageing be associated with & what does it impact?

Answer 4

Associated with physiological changes that can impact on nutritional status

Psychosocial and environmental changes, such as isolation, loneliness, depression and inadequate finances, which can have significant impacts on diet.

Question 5

What can physiological changes be caused by?

Answer 5

• sensory impairments (decreased sense of taste or smell)
• reduced appetite
• dental problems
• impaired gastric acid secretion
• limited mobility and ability to care for oneself

Question 6

Consequences to ageing?

Answer 6

• There are consequences to ageing including movement function, sensory function (hearing and vision), cognitive function (dementia etc), and immune function
• Multiple-morbidities:
• Anxiety and depression
• Osteoarthritis
• Dementia
• COPD
• Diabetes
• Cancer
• Ischaemic heart disease
• Stroke
• Hearing and vision impairments
• Falls

Question 7

Those living longer and their added years are in good health are more likely to…

Answer 7

Contribute to society

Question 8

Those living longer but experiencing poor health…

Answer 8

May mean increased demands on health and social care

Question 9

Underlying principles of ageing & long term care?

Answer 9

• Long-term care should be affordable and accessible
• Care should be provided to enhance older people’s dignity, and enables their self-expression
• Care should be person-centred and focused around the needs of the older person rather than the structure
• Regulation of these structures is important
• Building workforce capacity and supporting of carers

Question 10

Why is Oral Health Important?

Answer 10

• Good oral health is important for well-being
• People living longer, keeping their dentition and needing more complex treatment
• Prevention is very important
• Mouth is a mirror of health and disease: systemic diseases, bacterial and viral infections and nutritional deficiencies

Question 11

How does oral health affect general health?

Answer 11

• Being free of pain and discomfort
• Ability to function: chewing, eating will have an impact on nutrition
• Ability to smile and socialise will have an impact on self-esteem and mental health
• Increased risk to infections: dental abscess, candidiasis, pneumonia
• Frailty, disability and dementia: increases risk of poor general and oral health and access to care

Question 12

Oral Health Needs of Older people?

Answer 12

• High levels of dental caries
• High prevalence of periodontal disease
• Tooth loss
• Mouth cancer
• Candida infection
• Dry mouth
• The oral health profiles of older people varies between high, middle and low income countries
• In high income countries such as the UK, older people are keeping their teeth longer

Question 13

How to manage patients with dementia?

Answer 13

• People with dementia may find it hard to communicate or co-operate.
• Those caring for them may not have the time, confidence or the training .
• It is important to recognise that some people have good days and bad days
• Try to find out the individual’s best time of day for mouth care.
• Use clear short instructions
• Smiling and using appropriate touch and reassuring gestures.
• It sometimes takes two people – one to distract, hold hands or encourage whilst the other brushes the teeth.

Question 14

General findings of oral health of older people in long term care?

Answer 14

• Older adults living in residential and nursing care homes are more likely to be edentulous, and less likely to have a functional dentition
• Older adults living in care homes have higher caries prevalence, where the majority of dentate residents have active caries
• Signs of severe untreated caries appear to be more common in the oldest age groups across all settings

Question 15

What is the access to dental care like for older people in long term care?

Answer 15

• Care home managers experience much more difficulty in accessing dental care for their residents
• Dental services are patchy and often no regular or emergency dental care arrangements exist

Question 16

Why are people who are hospitalised associated with a deterioration in oral health?

Answer 16

• Increase in hospital acquired infections
• Poor nutritional intake
• Longer hospital stays
• Increased care costs

Question 17

What is the ambition for oral health for vulnerable older people?

Answer 17

• To be able to eat, sleep, socialise & maintain this throughout life
• Live well - as people age they are able to eat, drink, speak, smile & socialise without pain discomfort or embarrassment
• Prevent well - people are supported by evidence-based advice & interventions to enable them to maintain a healthy life throughout their lives
• Support well - throughout any phases of dependency or frailty, carers are trained & equipped to support daily mouth care & facilitate access to dental services
• Die well - people have the support they need to ensure their mouths remain free from pain & discomfort & to help them maintain dignity until the end of their lives

Question 18

What are the 5 As regarding access to healthcare?

Answer 18

Availability
Affordability
Acceptability
Physical accessibility
Accommodation

Question 19

What is definition of the 5 As?

Answer 19

Availability
- refers to the adequacy of supply given by the relationship between volume and type of services (provision) and volume and type of needs (demand).

Affordability
- applies to the cost implications to the patient in relation to need

Acceptability
- refers to attitudes and beliefs of users and providers about each other’s characteristics.

Physical accessibility
- is defined by the suitability of the location of the service in relation to the location and mobility of the patient (geographical and physical barriers).

Accommodation
- refers to the way services are organised in relation to the client’s needs and the patient’s perception of their appropriateness (opening times, booking facilities, waiting times).

Question 20

What is the case for action for the ageing population?

Answer 20

Older people have the skills, experience and wisdom to make a positive contribution to society

Question 21

Ageing Population and the Public Health
Response

Answer 21

• A systems-wide response to promote active ageing with Integration of health and social care for best outcomes
• Health systems need to adapt to manage health conditions in older age groups adopting a multi- disciplinary approach and not treating conditions in silos
• Health systems need to be affordable and accessible to older people

Question 22

NICE guideline recommendation to managers of care homes?

Answer 22

Managers ensure their home’s policies set out plans and actions to promote and protect people’s oral health.

Question 23

8 guidances set out by NICE for oral health in care homes?

Answer 23

1.Raise awareness with all relevant partner organisations.

2. Identify an oral health champion
3. Carry out a baseline assessment against the recommendations to find out whether there are gaps in current service provision.
4. Think about what data you need to measure improvement and plan how you will collect it
5. Develop an action plan, to put the guideline into practice, and make sure it is ready as soon as possible.
6. For very big changes include milestones and a business case, which will set out additional costs, savings and possible areas for disinvestment. A small project group could develop the action plan.
7. Implement the action plan with oversight from the lead and the project group.
8. Review and monitor how well the guideline is being implemented through the project group. Share progress with those involved in making improvements, as well as relevant boards and local partners

Question 24

NICE states care home policies set out plans and actions to promote and protect residents’ oral health, what should they include information about?

Answer 24

• local general dental services and emergency or out-of-hours dental treatment
• community dental services
• oral health promotion or similar services,
• assessment of residents’ oral health and referral to dental practitioners
• plans for caring for residents’ oral health and daily mouth care and use of mouth and denture care product

Question 25

Recommendation 1: Adults who move into a care home should have their mouth care needs assessed on admission- oral health ASSESSMENT

What is the rationale behind this?

Answer 25

o Self-care can deteriorate before a person moves into a care home, so they may be admitted with poor oral health.
o Mouth care may be missed if not specifically assessed.
o Mouth care needs should be assessed so that tailored care can start straight away (nurse-led assessment)

Question 26

Recommendation 2: Adults living in care homes have their mouth care needs RECORDED in their personal care plan.

What is the rationale behind this?

Answer 26

• This will help to make sure that action is taken to meet the person’s needs
• Mouth care needs are regularly reviewed.
• Referral to local NHS dental services- collaborate with local
  dental services

Question 27

Recommendation 3: Adults living in care homes are supported to MAINTAIN their oral health

What is the rationale behind this?

Answer 27

For good oral health
* Adults with natural teeth should brush them with fluoride toothpaste twice a day
* Adults with full dentures should carry out daily care and removing dentures overnight.
* Adults with both natural teeth and partial dentures should do both.
* Good oral health is important to maintain self-esteem, dignity and quality of life. Adults with poor oral health often have problems with eating, speaking and socialising.
* Collaborate with nurses, HCAs etc.

Question 28

Interventions to improve Oral Health of residents in Care Homes?

Answer 28

• Use of dentifrices containing 2,800 or 5,000 ppm F to prevent or arrest caries in dentate vulnerable older people
• Good evidence for the effectiveness of quarterly application of fluoride varnish.
• Oral hygiene regime to improve oral health and possibly reduce the risk of aspiration pneumonia
• Training of car home staff on oral health
• Protocols of oral care and an oral health champion
• Dietary changes to promote health eating
• Outreach into care homes

Question 29

What healthy food & snack policies can the care home have?

Answer 29

Healthy snacks include:
* Tea and coffee (no sugar, use sweetener instead)
* Water (to be always available and drinking encouraged
* Fruit
* Breadsticks, savoury biscuits
* Cheese

Sugar and special diets
* Care staff usually comply with any nutritional or dietetic requirements advised by medical or other healthcare professionals
* Some nutritional food supplements may contain sugar and will increase risk of dental decay. Therefore prevention and increasing the availability of fluorides is vital.

Question 30

How should care home staff be trained?

Answer 30

• Limited formal training in mouth care in agreement with other studies-A study conducted at a neuro-disability hospital in London found that nursing staff may find it challenging providing care to uncooperative or agitated patients due to lack of skills in using alternative techniques
• Training of the care home staff to enhance their knowledge, skills and behaviours in providing oral health care for residents
• Training can be offered by the domiciliary dentist or an oral health promotion team
• Care staff can observe a correct approach and learn simple techniques, such as use of a second brush where mouth opening is restricted

Question 31

Ensure care staff who provide daily personal care to residents…

Answer 31

• Understand the importance of residents’ oral health and the potential effect on their general health, wellbeing and dignity.
• Understand the potential impact of untreated dental pain or mouth infection on the behaviour, and general health and wellbeing of people who cannot articulate their pain or distress or ask for help.
• Know how and when to reassess residents’ oral health
• Know how to deliver daily mouth care
• Know how and when to report any oral health concerns for residents, and how to respond to a resident’s changing needs and circumstances.
• Understand the importance of denture marking and how to arrange this for residents, with their permission.

Question 32

How to care for residents in end of life palliative care?

Answer 32

• Paying attention to mouth care is crucial when person is receiving palliative care or is nearing the end of life.
• To prevent or relieve mouth pain or discomfort, regular assessment, good care and a sensitive approach are essential:
  *If the person can tolerate brushing, a very soft, small-headed toothbrush is recommended.
• Dentures should be kept clean.
• Saliva-replacement gels on lips can be used to stop lips becoming dry.
• If the resident shows any signs of a painful mouth, a dentist should be asked to visit for an oral health assessment and treatment

Question 33

How to improve access to dental & oral health promotion services?

Answer 33

• Mixed model: general dental services, community dental services, specialist dental services
• Domiciliary Care
• Training of dental teams
• Oral health promotion services